Rehabilitation For Persistent Pain Across The Lifespan

Rehabilitation for
Persistent Pain
across the Lifespan
Edited by
Jo Nijs and Kelly Ickmans
Printed Edition of the Special Issue Published in
Journal of Clinical Medicine
www.mdpi.com/journal/jcm
Rehabilitation for Persistent Pain
across the Lifespan
Rehabilitation for Persistent Pain
across the Lifespan
Editors
Jo Nijs
Kelly Ickmans
MDPI • Basel • Beijing • Wuhan • Barcelona • Belgrade • Manchester • Tokyo • Cluj • Tianjin
Editors
Jo Nijs KellyIckmans
Department of Physiotherapy, ȱȱ¢¢ǰȱ
Human Physiology and ȱ¢¢ȱȱ¢ǰȱ
Anatomy, Faculty of Physical ¢ȱȱ¢ȱȱ
Education and Physiotherapy, ȱ¢¢ǰȱ
Vrije Universiteit Brussel ȱȱ
Belgium
Editorial Office
MDPI
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4052 Basel, Switzerland
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Contents
About the Editors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii
Kelly Ickmans, Lennard Voogt and Jo Nijs

Rehabilitation Succeeds Where Technology and Pharmacology Failed: Effective Treatment of
Persistent Pain across the Lifespan
Reprinted from: J. Clin. Med. 2019, 8, 2042, doi:10.3390/jcm8122042 . . . . . . . . . . . . . . . . . 1
Jo Nijs, Kelly Ickmans, David Beckwée and Laurence Leysen

Behavioral Graded Activity+ (BGA+ ) for Osteoarthritis: A Paradigm Shift from Disease-Based
Treatment to Personalized Activity Self-Management
Lauren E. Harrison, Joshua W. Pate, Patricia A. Richardson, Kelly Ickmans, Rikard K.

Wicksell and Laura E. Simons
Best-Evidence for the Rehabilitation of Chronic Pain Part 1: Pediatric Pain
An De Groef, Frauke Penen, Lore Dams, Elien Van der Gucht, Jo Nijs and Mira Meeus
Best-Evidence Rehabilitation for Chronic Pain Part 2: Pain during and after Cancer Treatment
Reprinted from: J. Clin. Med. 2019, 8, 979, doi:10.3390/jcm8070979 . . . . . . . . . . . . . . . . . . 31
Anneleen Malfliet, Kelly Ickmans, Eva Huysmans, Iris Coppieters, Ward Willaert, Wouter
Van Bogaert, Emma Rheel, Thomas Bilterys, Paul Van Wilgen and Jo Nijs
Best Evidence Rehabilitation for Chronic Pain Part 3: Low Back Pain
Michele Sterling, Rutger M. J. de Zoete, Iris Coppieters and Scott F. Farrell

Best Evidence Rehabilitation for Chronic Pain Part 4: Neck Pain
David Rice, Peter McNair, Eva Huysmans, Janelle Letzen and Patrick Finan
Best Evidence Rehabilitation for Chronic Pain Part 5: Osteoarthritis
Thomas Probst, Robert Jank, Nele Dreyer, Stefanie Seel, Ruth Wagner, Klaus Hanshans,
Renate Reyersbach, Andreas Mühlberger, Claas Lahmann and Christoph Pieh
Early Changes in Pain Acceptance Predict Pain Outcomes in Interdisciplinary Treatment for
Chronic Pain
Adrián Pérez-Aranda, Francesco D’Amico, Albert Feliu-Soler, Lance M. McCracken, Marı́a T.

Peñarrubia-Marı́a, Laura Andrés-Rodrı́guez, Natalia Angarita-Osorio, Martin Knapp, Javier
Garcı́a-Campayo and Juan V. Luciano
Cost–Utility of Mindfulness-Based Stress Reduction for Fibromyalgia versus a Multicomponent
Intervention and Usual Care: A 12-Month Randomized Controlled Trial (EUDAIMON Study)
Luis Suso-Martı́, Jose Vicente León-Hernández, Roy La Touche, Alba Paris-Alemany and
Ferran Cuenca-Martı́nez
Motor Imagery and Action Observation of Specific Neck Therapeutic Exercises Induced
Hypoalgesia in Patients with Chronic Neck Pain: A Randomized Single-Blind Placebo Trial
v
Åsa Ringqvist, Elena Dragioti, Mathilda Björk, Britt Larsson and Björn Gerdle
Moderate and Stable Pain Reductions as a Result of Interdisciplinary Pain Rehabilitation—A
Cohort Study from the Swedish Quality Registry for Pain Rehabilitation (SQRP)
Matthias Vogel, Martin Krippl, Lydia Frenzel, Christian Riediger, Jörg Frommer, Christoph
Lohmann and Sebastian Illiger
Dissociation and Pain-Catastrophizing: Absorptive Detachment as a Higher-Order Factor in
Control of Pain-Related Fearful Anticipations Prior to Total Knee Arthroplasty (TKA)
Ann-Christin Pfeifer, Pamela Meredith, Paul Schröder-Pfeifer, Juan Martin Gomez Penedo,
Johannes C. Ehrenthal, Corinna Schroeter, Eva Neubauer and Marcus Schiltenwolf
Effectiveness of an Attachment-Informed Working Alliance in Interdisciplinary Pain Therapy
Manuel Albornoz-Cabello, Jose Antonio Sanchez-Santos, Rocio Melero-Suarez, Alberto

Marcos Heredia-Rizo and Luis Espejo-Antunez
Effects of Adding Interferential Therapy Electro-Massage to Usual Care after Surgery in
Subacromial Pain Syndrome: A Randomized Clinical Trial
Zoë C. Franklin, Paul S. Holmes and Neil E. Fowler

Eye Gaze Markers Indicate Visual Attention to Threatening Images in Individuals with Chronic
Back Pain
Elena Dragioti, Mathilda Björk, Britt Larsson and Björn Gerdle

A Meta-Epidemiological Appraisal of the Effects of Interdisciplinary Multimodal Pain Therapy
Dosing for Chronic Low Back Pain
Jon Ford, Andrew Hahne, Luke Surkitt, Alexander Chan and Matthew Richards
The Evolving Case Supporting Individualised Physiotherapy for Low Back Pain
Liye Zou, Yanjie Zhang, Lin Yang, Paul D. Loprinzi, Albert S. Yeung, Jian Kong, Kevin W
Chen, Wook Song, Tao Xiao and Hong Li
Are Mindful Exercises Safe and Beneficial for Treating Chronic Lower Back Pain? A Systematic
Review and Meta-Analysis of Randomized Controlled Trials
vi
About the Editors
Jo Nijs holds a PhD in rehabilitation science and physiotherapy. He is Professor at the Vrije
Universiteit Brussel (Brussels, Belgium), physiotherapist/manual therapist at the University Hospital
Brussels, Chair of oncological physiotherapy funded by the Berekuyl Academy, the Netherlands,
and part of the Visiting Professor program of the University of Gothenburg (Sweden). Jo runs
the Pain in Motion international research group (www.paininmotion.be). His research and clinical
interests are patients with chronic pain and pain–movement interactions, with special emphasis on
the central nervous system. The primary aim of his research is improving care for patients with
chronic pain. At the age of 44, he has (co-)authored >260 peer reviewed publications (including
papers in high impact journals such as The Lancet and JAMA Neurology), obtained €9.5 million
grant income, supervised 18 PhD projects to completion and served on more than 290 occasions
as an invited speaker at national and international meetings in 25 different countries (including
33 keynotes). He has trained around 3000 clinicians in 92 courses held in 12 different countries
spread over 4 continents. His work has been cited over 7000 times (h-index: 47), with 26 citations per
article (ISI Web of Knowledge). Jo is ranked 2nd in the world among chronic pain researchers (1st in
Europe; expertscape.com), received the 2017 Excellence in Research Award from the JOSPT (USA),
and the 2020 Francqui Collen Chair awarded by the University of Hasselt, Belgium.
Kelly Ickmans is part time Postdoctoral Research Fellow at the Research Foundation Flanders (FWO),
Vrije Universiteit Brussel (Brussels, Belgium), where she is also part time Assistant Professor (ZAP).
She is also an attending physiotherapist at the University Hospital Brussels (Brussels, Belgium)
where she treats adults and children with chronic pain. In 2014, Kelly obtained her PhD in
Rehabilitation Sciences and Physiotherapy. Within the international Pain in Motion research group
(www.paininmotion.be), she leads the line of research on pediatric pain. Since the start of her research
career in 2011, Kelly has (co-)authored over 80 peer-reviewed publications in international journals,
including several papers in high impact journals. Her work has been cited over 1000 times in the
scientific literature (h-index 18) with an average of 13 citations per article. She has furthermore
published 4 chapters in (inter)national handbooks, served dozens of times as an invited speaker at
national and international meetings in 8 different countries, delivered over 30 post-academic and
refresher courses in different countries over the world, supervised 3 PhD projects to completion,
and is currently (co-)supervisor of 8 PhD projects.
vii
Journal of
Clinical Medicine
Editorial
Rehabilitation Succeeds Where Technology and
Pharmacology Failed: Effective Treatment of
Persistent Pain across the Lifespan
Kelly Ickmans 1,2,3, *, Lennard Voogt 1,4,5 and Jo Nijs 1,2
1 Pain in Motion International Research Group, Department of Physiotherapy, Human Physiology and
Anatomy, Faculty of Physical Education & Physiotherapy, Vrije Universiteit Brussel, Laarbeeklaan 103,
1090 Brussels, Belgium; l.p.voogt@hr.nl (L.V.); jo.nijs@vub.be (J.N.)
2 Department of Physical Medicine and Physiotherapy, Universitair Ziekenhuis Brussel, Laarbeeklaan 101,
1090 Brussels, Belgium
3 Research Foundation-Flanders (FWO), 1000 Brussels, Belgium
4 Research Centre for Health Care Innovations, Rotterdam University of Applied Sciences,
3015 EK Rotterdam, The Netherlands
5 Department of Physical Therapy Studies, Rotterdam University of Applied Sciences,
3015 EK Rotterdam, The Netherlands
* Correspondence: Kelly.Ickmans@vub.be; Tel.: +32-(0)24774503
Received: 14 November 2019; Accepted: 18 November 2019; Published: 21 November 2019
Chronic pain affects up to 30% of the adult population [1] and 11% to 38% of the childhood and
adolescent population [2,3]. Its tremendous personal and socioeconomic impact is reflected by its
cause of the highest number of years lived with disability [4] and being the most expensive cause
of work-related disability in adults [5,6]. In children and adolescents, chronic pain causes decreased
participation in recreational activities, difficulty maintaining social contacts, school absence and
academic impairment, decreased health related quality of life, and increased health care utilization [3,7].
The area of rehabilitation research for patients having persistent pain is on the move with a
substantial increase in the scientific understanding of persistent pain over the past decades. This rapid
growth in pain science has inspired rehabilitation clinicians and researchers around the globe, leading
to breakthrough research and the implementation of contemporary pain science in rehabilitation
settings. Still, our understanding of persistent pain continues to grow, not in the least because of
fascinating discoveries from areas such as psychoneuroimmunology, epigenetics, exercise physiology,
clinical psychology, and nutritional (neuro)biology. This offers unique opportunities to further improve
rehabilitation for patients with chronic pain. As age is a determining factor in the uniqueness of the bio-,
psycho-, and social factors of persistent pain, this also implies that rehabilitation interventions should
be tailored across the lifespan. Also, the diversity of health care disciplines involved in the rehabilitation
of chronic pain (e.g., physicians, psychologists, physiotherapists, occupational therapists, nurses,
coaches) provides a framework for upgrading rehabilitation for chronic pain towards comprehensive
lifestyle approaches.
A number of articles published in this Special Issue draw specific attention to interdisciplinary
multimodal rehabilitation programs for chronic pain. Ringqvist et al. [8] provide evidence that such
programs delivered to adults in specialist care show moderate long-term effect sizes for pain, pain
interference in daily life, and perceived health. Interestingly, Pfeifer et al. [9] provide preliminary
support for the utility of incorporating an attachment-informed approach within these existing
multimodal pain therapies, thereby aiming at advancing the working alliance between patient and
therapist. In the realm of pediatric chronic pain rehabilitation, Harrison et al. [10] state that preliminary
evidence on interdisciplinary outpatient treatments is promising with regard to improvements in pain
intensity, pain-related disability, school attendance, catastrophizing, and symptoms of depression.
J. Clin. Med. 2019, 8, 2042; doi:10.3390/jcm8122042 1 www.mdpi.com/journal/jcm

J. Clin. Med. 2019, 8, 2042
In addition, addressing multiple unfavorable lifestyle factors, such as physical inactivity, sedentary
behavior, stress, smoking, unhealthy diet, and poor sleep concomitantly, seems to be a challenge for
which such interdisciplinary pain rehabilitation programs may offer a comprehensive framework.
Indeed, unfavorable lifestyle factors and pain have been shown to be interconnected [11]. This suggests
that multimodal lifestyle-centered approaches may be effective for chronic pain. Actually, this matter
is touched on in each of the five invited contributions on the best evidence rehabilitation for chronic
pain [10,12–15], thus underscoring its topicality for persistent pain rehabilitation and providing
important avenues for future research.
The invited contributions in this Special Issue are part of a “Best Evidence Rehabilitation for Chronic
Pain” Series comprising five state-of-the-art papers from world leading experts regarding persistent
pain. Part 1, by Harrison et al. [10], covers the current state-of-the-art rehabilitation approaches to
treat persistent pain in children and adolescents. In addition, several emerging areas of interventions
are highlighted to guide future research and clinical practice. Part 2, the article by De Groef et al. [12],
provides the reader with a state-of-the-art overview of the best evidence rehabilitation modalities for
patients having (persistent) pain during and following cancer treatment. This paper is of particular
importance to the field of oncology, especially now that common practices to manage cancer pain
are being challenged due to a lack of supporting evidence [16,17]. In parts 3 and 4, Malfliet et al. [13]
and Sterling et al. [14] present an overview of the best evidence non-invasive rehabilitation for people
having chronic low back pain and neck pain, respectively. Finally, in part 5, a state-of-the-art review
of rehabilitation for osteoarthritis pain is provided by Rice et al. [15]. For each of these domains,
the best evidence rehabilitation is reviewed in a way that clinicians can integrate it into their daily
clinical routine. The “Best Evidence Tables”, “Future Directions for Clinical Practice” sections, and key
references to treatment manuals included in each of these papers serve to meet that aim. In addition,
these overview articles also help clinical researchers to build upon the best evidence for designing
future trials, implementation studies, and new innovative studies.
In summary, the collection of high-quality work presented in this Special Issue provides important
new evidence from experimental lab-based as well as clinical studies, all focusing on rehabilitation
for people with persistent pain. The review articles included in the “Best Evidence Rehabilitation
for Chronic Pain” Series together delineate an important trend of continuously growing evidence
supporting rehabilitation approaches for people with chronic pain. The more rehabilitation programs
for people with chronic pain develop into multimodal lifestyle approaches, the stronger the evidence
supporting them as key elements in the treatment for chronic pain. This is in sharp contrast with medical
interventions for chronic pain such as (spinal) surgery, interventional treatments such as radiofrequency
denervation, and analgesics that struggle following rigorous scientific evaluation [18–20], especially
when side effects and cost-effectiveness are taken into account. Rehabilitation is succeeding where
technology and pharmacology failed: providing effective treatment for people suffering from chronic
pain. Still, much work needs to be done regarding implementation as well as scientific research.
Therefore, we believe that the original and novel information along with the overview papers within the
“Best Evidence Rehabilitation for Chronic Pain” Series in this Special Issue will serve as an important
resource for researchers and an aid for clinicians to facilitate integration from research into daily clinical
practice. Thereby, we hope to serve as a guiding light for future research in this area and to aid in
further improvements in the quality of care for people with persistent pain across the lifespan.
Acknowledgments: No funding nor sponsorship was received for the present paper. Kelly Ickmans is a
postdoctoral research fellow funded by the Research Foundation – Flanders (FWO). Jo Nijs is holder of a Chair
entitled “Exercise immunology and chronic fatigue in health and disease” funded by the Berekuyl Academy,
The Netherlands.
Conflicts of Interest: The authors declare no conflict of interest.
2
J. Clin. Med. 2019, 8, 2042
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9. Pfeifer, A.C.; Meredith, P.; Schroder-Pfeifer, P.; Gomez Penedo, J.M.; Ehrenthal, J.C.; Schroeter, C.; Neubauer, E.;
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Yilmaz, S.; Elma, O.; et al. Lifestyle and chronic pain across the lifespan: An inconvenient truth? PM R J. Inj.
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19. Juch, J.N.S.; Maas, E.T.; Ostelo, R.; Groeneweg, J.G.; Kallewaard, J.W.; Koes, B.W.; Verhagen, A.P.;
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© 2019 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access
article distributed under the terms and conditions of the Creative Commons Attribution
(CC BY) license (http://creativecommons.org/licenses/by/4.0/).
4
Journal of
Clinical Medicine
Editorial
Behavioral Graded Activity+ (BGA+) for
Osteoarthritis: A Paradigm Shift from Disease-Based
Treatment to Personalized Activity Self-Management
Jo Nijs 1,2,3, *, Kelly Ickmans 1,2,4 , David Beckwée 5 and Laurence Leysen 1,5
Anatomy, Faculty of Physical Education & Physiotherapy, Vrije Universiteit Brussel, BE-1090 Brussels,
Belgium; kelly.ickmans@vub.be (K.I.); Laurence.Leysen@vub.be (L.L.)
2 Chronic Pain Rehabilitation, Department of Physical Medicine and Physiotherapy,
University Hospital Brussels, BE1090 Brussels, Belgium
3 Institute of Neuroscience and Physiology, University of Gothenburg, Box 430, SE-405 30 Göteborg, Sweden
4 Flemish Research Foundation (FWO), BE1050 Brussels, Belgium
5 Rehabilitation Research Group, Department of Physiotherapy, Human Physiology and Anatomy,
Faculty of Physical Education & Physiotherapy, Vrije Universiteit Brussel, BE-1090 Brussels, Belgium;
david.beckwee@vub.be
* Correspondence: Jo.Nijs@vub.be; Tel.: +32-2477-4489
Received: 3 June 2020; Accepted: 4 June 2020; Published: 9 June 2020
Abstract: Three promising directions for improving care for osteoarthritis (OA) include novel
education strategies to target unhelpful illness and treatment beliefs; methods to enhance the efficacy
of exercise interventions; and innovative, brain-directed treatments. Here we explain that each of
those three promising directions can be combined through a paradigm-shift from disease-based
treatments to personalized activity self-management for patients with OA. Behavioral graded activity
(BGA) accounts for the current understanding of OA and OA pain and allows a paradigm shift
from a disease-based treatment to personalized activity self-management for patients with OA.
To account for the implementation barriers of BGA, we propose adding pain neuroscience education
to BGA (referred to as BGA+ ). Rather than focusing on the biomedical (and biomechanical) disease
characteristics of OA, pain neuroscience education implies teaching people about the underlying
biopsychosocial mechanisms of pain. To account for the lack of studies showing that BGA is “safe”
with respect to disease activity and the inflammatory nature of OA patients, a trial exploring the
effects of BGA+ on the markers of inflammation is needed. Such a trial could clear the path for
the required paradigm shift in the management of OA (pain) and would allow workforce capacity
building that de-emphasizes biomedical management for OA.
Keywords: rehabilitation; chronic pain; inflammation
1. Introduction
Given the high number of treatment guidelines available, clinicians might be overwhelmed by
the evidence on osteoarthritis (OA) management. Taking into account the socio-economic impact and
high prevalence of OA, it is imperative that healthcare professionals have free access to up-to-date,
evidence-based information to assist them in treatment decision-making. Therefore, in the Journal
of Clinical Medicine‘s Special Issue on “Rehabilitation for Persistent Pain Across the Lifespan”,
Rice et al. provide a state-of-the-art review of rehabilitation for OA pain [1]. In addition to providing
a comprehensive and easily consumable overview of the best evidence on rehabilitation for OA
pain, they also explore promising directions for clinical practice and discuss potential future research
avenues. The promising directions for clinical practice include novel education strategies to target

J. Clin. Med. 2020, 9, 1793
unhelpful illness and treatment beliefs; methods to enhance the efficacy of exercise interventions;
and innovative, brain-directed treatments [1]. Here we explain that each of those three promising
directions can be combined through a paradigm-shift from disease-based treatments to personalized
activity self-management for patients with OA.
2. Disease-Based Osteoarthritis Treatment Offers Modest Effect Sizes

Current OA treatment guidelines have a disease-based, biomedical focus (e.g., joint replacement
surgery). Even education and exercise therapy, cornerstones of international OA treatment
guidelines [2–5], have a disease-based focus; education typically consists of accurate information
to enhance the understanding of the condition (hip or knee OA) and its consequences, while the
progression of exercises is typically guided by tolerable levels of pain and the patient’s ability to perform
a given exercise. Such a disease-based, biomedical focus is offline with our current understanding of
OA pain [6], including its biopsychosocial nature and the role of central sensitization in amplifying the
OA pain experience [7]. The effect sizes of disease-based education and exercise therapy for OA are
moderate at best [5], allowing room for improvement. Such improvement might come from modifying
existing disease-based educational and exercise therapy interventions to our current understanding of
OA pain [6,8].
3. Personalized Activity Self-Management for Patients with Osteoarthritis

High all-cause mortality from knee OA is mediated mainly through walking disability [9],
and encouraging people to walk and “get out and about” in addition to targeting OA can be protective
against excessive mortality [10]. However, to people with OA, pain represents a major barrier to
walking or any other physical activity [11–13]. An innovative and effective way of accounting for the
current biopsychosocial understanding of OA pain and encouraging people to walk and “get out and
about” and addressing pain as a barrier to physical activity, is through using behavioral-graded activity
(BGA). BGA is a behavioral treatment integrating the concept of operant conditioning to increase the
level of physical activity in the patient’s daily life [14]. It is a highly personalized approach, targeting
the patients’ activity limitations and self-defined treatment goals (goal setting), and individually
tailoring the baseline and grading levels for performing these daily activities. BGA allows OA patients
to shift from having priority in pain control to priority in valued life goals.
The use of BGA for patients with OA pain is supported by a cluster-randomized clinical trial [14,15],
suggesting that BGA is an effective treatment for relieving pain, improving physical functioning and
physical performance, and preventing joint replacement surgery in patients with OA [14,15]. Compared
to usual care, BGA resulted in superior exercise adherence and more physical activity in people with
hip or knee OA [16]. Such increased physical activity levels not only result in less pain [17] but also
hold the potential to decrease the low-grade inflammation that is characteristic of OA. Indeed, OA is
characterized by a chronic low-grade inflammatory profile [18–20], and physical activity has strong
anti-inflammatory effects [21–26], but studies in OA remain scarce. With its anti-inflammatory action,
physical activity might even contribute to decreasing the mortality risk in patients with OA [27–29].
4. Implementation Barriers for a Personalized Activity Self-Management Approach

BGA accounts for the current understanding of OA and OA pain and allows a paradigm shift from
a disease-based treatment to personalized activity self-management for patients with OA (Table 1).
However, more than 10 years after the initial trial findings were published, BGA is not recommended
by the European [30], American [4], or international [3] guidelines for OA management, preventing
its implementation in clinical practice. Another implementation barrier relates to the common belief
among both patients and therapists that OA pain is a “warning sign” of disease severity. Up to 89% of
future therapists consider severe pain a reason for not using exercise in the treatment of OA, while
87% believe that increasing overall activity levels cannot stop the knee problem getting worse [31].
A multinational study concluded that workforce capacity building that de-emphasizes biomedical
6
J. Clin. Med. 2020, 9, 1793
management for OA is urgently needed [32]. Beliefs about the consequences of exercise account for
general practitioners’ use of exercise in knee pain [33] (with 29% believing that rest was the optimum
management approach for knee OA [34]). To account for these implementation barriers, we propose
adding pain neuroscience education to BGA (referred to as BGA+ ).
Table 1. Proposed paradigm shift from disease-based treatment to personalized activity

self-management for osteoarthritis.
Current Best-Evidence:
Personalized Activity Self-Management
Disease-Based Treatment
Disease-based, biomedically
Biopsychosocial education
focussed eduation
Exercises target muscle
Physical activities targeting self-defined functional
strength, endurance,
and/or social activities and life goals
motor control, etc.
Pain = sign of tissue damage,
Pain = sign of nervous system sensitivity
including inflammation
Pain contingent approach Operant conditioning and time contingent approach
to grading exercises to grading daily activities
5. Pain Neuroscience Education + Behavioral Graded Activity = BGA+

Indeed, patients with OA are confused about the cause of their pain and bewildered by its variability
and randomness [35]. Without adequate information and advice from healthcare professionals, people
do not know what they should and should not do, and, as a consequence, avoid activity for fear of
causing harm. A Cochrane review concluded that providing reassurance and clear advice about the
value of exercise in OA and opportunities to participate in exercise programs that people regard as
enjoyable and relevant to their personal life may encourage greater exercise participation, which brings a
range of health benefits to patients with OA [36]. Therefore, the addition of pain neuroscience education
to BGA entails a dramatic shift in educating OA patients prior to exercise/activity interventions.
As explained by Rice et al. [1], rather than focusing on the biomedical (and biomechanical) disease
characteristics of OA, pain neuroscience education implies teaching people about the underlying
biopsychosocial mechanisms of pain. Pain neuroscience education is a remarkable example of how
patients who receive proper guidance can really help themselves. Pain neuroscience education prepares
patients for a time-contingent (“Perform the activity/exercise for five minutes, regardless of the pain.”),
cognition-targeted approach to daily (physical) activity and exercise therapy, as typically applied
during BGA. Such a time-contingent approach replaces the classical symptom-contingent (“Stop the
activity/exercise once it hurts”) approach. A time-contingent approach to activities is often difficult for
patients to comprehend and comply with and for therapists to implement. Indeed, a time-contingent
approach to activities/exercises contradicts with the disease-based, biomedical focus on exercise and
activity interventions with which therapists are often more comfortable with [37]. Pain neuroscience
education specifically addresses this barrier for making a the paradigm shift to personalized activity
self-management for patients with OA, both at the patient and the therapist level.
In a recent proof-of-concept study, we reported that pain neuroscience education, compared to
biomedical-focused education, generates favorable effects on decreasing pain catastrophizing, excessive
attention to pain, and activity-related fear at short and long-term follow-ups in people with knee
OA [38]. In addition, a case series of 12 OA patients receiving pain neuroscience education prior to
joint replacement surgery revealed that the fear of movement and sensitivity to pain decreased [39].
6. Conclusions
Taken together, BGA+ addresses all three promising directions for clinical practice highlighted by
Rice et al. [1]. BGA+ includes a novel education strategy to target unhelpful illness and treatment beliefs;
applies evidence-based methods to enhance the efficacy of physical activity/exercise interventions;
7
J. Clin. Med. 2020, 9, 1793
and can be considered an innovative, brain-directed treatment. Hence, BGA+ allows a paradigm-shift
from disease-based treatments to personalized activity self-management for patients with OA. Still,
to account for the implementation barrier, where OA patients fear that moving despite pain might
aggravate disease activity, as well as the lack of studies showing that BGA is “safe” with respect to
disease activity and the inflammatory nature of OA patients (therapist barrier), a trial exploring the
effects of BGA+ on the markers of inflammation in patients with OA is urgently needed. Such a trial
could clear the path for the required paradigm shift in the management of OA (pain) and would allow
workforce capacity building that de-emphasizes biomedical management for OA [32].
Author Contributions: Conceptualization, J.N.; writing—original draft preparation, J.N.; writing—review and
editing, J.N., K.I., D.B., L.L.; supervision, L.L. All authors have read and agreed to the published version of
the manuscript
Funding: This research received no external funding.
Conflicts of Interest: J.N. coauthored a Dutch book on pain neuroscience education, but the royalties are collected
by the Vrije Universiteit Brussel and not him personally. Besides that, the authors declare no conflict of interest.
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10
Journal of
Clinical Medicine
Review
Best-Evidence for the Rehabilitation of Chronic Pain
Part 1: Pediatric Pain
Lauren E. Harrison 1 , Joshua W. Pate 2 , Patricia A. Richardson 1 , Kelly Ickmans 3,4,5,6 ,
Rikard K. Wicksell 7 and Laura E. Simons 1, *
1 Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine,
Stanford, CA 94304, USA
2 Faculty of Medicine and Health Sciences, Macquarie University, Sydney, NSW 2109, Australia
3 Research Foundation-Flanders (FWO), 1000 Brussels, Belgium
4 Department of Physiotherapy, Human Physiology and Anatomy (KIMA), Faculty of Physical Education &
Physiotherapy, Vrije Universiteit Brussel, 1090 Brussels, Belgium
5 Pain in Motion International Research Group, 1090 Brussels, Belgium
6 Department of Physical Medicine and Physiotherapy, University Hospital Brussels, 1090 Brussels, Belgium
7 Department of Clinical Neuroscience, Psychology division, Karolinska Institutet, 171 65 Stockholm, Sweden
* Correspondence: lesimons@stanford.edu; Tel.: +32-650-736-0838
Received: 15 July 2019; Accepted: 16 August 2019; Published: 21 August 2019
Abstract: Chronic pain is a prevalent and persistent problem in middle childhood and adolescence.
The biopsychosocial model of pain, which accounts for the complex interplay of the biological,
psychological, social, and environmental factors that contribute to and maintain pain symptoms
and related disability has guided our understanding and treatment of pediatric pain. Consequently,
many interventions for chronic pain are within the realm of rehabilitation, based on the premise
that behavior has a broad and central role in pain management. These treatments are typically
delivered by one or more providers in medicine, nursing, psychology, physical therapy, and/or
occupational therapy. Current data suggest that multidisciplinary treatment is important, with
intensive interdisciplinary pain rehabilitation (IIPT) being effective at reducing disability for patients
with high levels of functional disability. The following review describes the current state of the art of
rehabilitation approaches to treat persistent pain in children and adolescents. Several emerging areas
of interventions are also highlighted to guide future research and clinical practice.
Keywords: chronic pain; children pain rehabilitation; best evidence
1. Introduction
Chronic pain is a prevalent problem among children and adolescents, with epidemiological data
indicating approximately 30% of children experience pain persisting for 3 months or longer [1,2].
The most common pain complaints in children include migraine, abdominal pain, and musculoskeletal
pain [1]. The presence of chronic pain has a significant negative impact on functioning, with impairments
across academic, social, and recreational domains, as well as family functioning [3]. Given this broad
impact, treatment for chronic pain typically focuses on functional improvements across domains.
Rehabilitation for chronic pain applies the biopsychosocial model [4], which accounts for the
complex interplay of the biological, psychological, social, and environmental factors that contribute to
and maintain pain symptoms and related disability. Most interventions for chronic pain are within
the realm of rehabilitation, based on the premise that behavior has a broad and central role in pain
management. These treatments are typically delivered by one or more providers in medicine, nursing,
psychology, physical therapy, and/or occupational therapy. In chronic pain management, as contrasted
with acute pain treatment, the emphasis shifts from immediate analgesia to functional improvements

J. Clin. Med. 2019, 8, 1267
in the presence of pain [5,6]. Given this, this review will focus solely on rehabilitation interventions,
including psychological, behavioral, and physiological interventions.
Given all of the domains involved and impacted by chronic pain, treatment typically requires
a comprehensive and multidisciplinary approach, most often achieved through psychological
interventions, as well as physical and occupational therapies [7]. Multidisciplinary teams often
consist of providers from several specialties who work together to develop a treatment plan for the
patient and family [8]. An interdisciplinary model, comprised of the same specialists, differs slightly
from a multidisciplinary team as the team members work together in a more fluid way (often housed
within the same institution or clinic), with more extensive collaboration and shared treatment goals [8].
Rehabilitative treatments are also delivered across several levels of care, including outpatient,
intensive outpatient (i.e., day treatment), and inpatient. Often thought of as the first level of care,
outpatient interventions can be collaborative and multidisciplinary (e.g., if a psychologist and physical
therapist were housed within the same medical system and occasionally corresponded regarding
patient progress). However, outpatient interventions are typically delivered independent of each
other. Unfortunately, adherence to treatment recommendations in outpatient pain clinics is often
suboptimal [9], which underscores the importance of thorough assessment and delivery of tailored
treatment approaches that best meet the individual needs of the child and family. Furthermore, patients
with more severe pain-related disability or who have been unsuccessful in outpatient therapies may
require more comprehensive and intensive interventions [8].
This review has several aims. First, we present an overview of the state-of-the-art of rehabilitative
interventions for children and adolescents with chronic pain. In order to present the best evidence
in rehabilitation for pediatric chronic pain, this review primarily relies on systematic reviews and
meta-analyses. However, to incorporate the most recent evidence, methodologically sound clinical
trials (e.g., randomized controlled trials, sample size > 20, clearly described interventions) that have not
yet been integrated into the available reviews are included as well. For this review, a non-systematic
search of the literature was performed in PubMed and Google Scholar using the following search
strategy: ((child OR pediatric) OR adolescent AND (chronic pain (Text Word)) AND rehabilitation
(Text Word)). The inclusion of chronic pain and rehabilitation terms resulted in a search that pulled for
the primary rehabilitative interventions used to treat pediatric chronic pain. All titles and abstracts
(total of 399) of articles were then separately screened by two authors (L.E.H., J.W.P.) for inclusion.
Our second aim is to inform clinicians of innovative and emerging treatments that can potentially
enhance treatment delivery and patient outcomes. Lastly, this review intends to identify evidence gaps
among interventions that warrant further study, and to serve clinical researchers to build upon the best
evidence for designing future trials, implementing studies, and developing innovative future studies.
2. State of the Art of Rehabilitation for Pediatric Chronic Pain

There is strong evidence to support early, targeted psychological and physiological intervention for
pediatric chronic pain, with most approaches sharing common features: Pain education, psychological
interventions, and physical and occupational therapies [7]. Psychological interventions for pediatric
chronic pain focus on the self-management of pain and disability, with the ultimate goal of a return to
baseline functioning [10,11]. Components of psychological interventions for chronic pain include, but
are not limited to, psychoeducation, relaxation training, identifying and addressing negative cognitions,
acceptance and values-based exercises, behavioral exposures, and parent coaching [12]. There is
substantial evidence suggesting these interventions are effective at reducing pain severity, disability,
and psychological distress (e.g., anxiety) in children with chronic pain [13–15]. Within pain conditions,
psychological interventions have been found to effectively reduce pain in headache, abdominal pain,
and musculoskeletal conditions, and functional disability in abdominal and musculoskeletal pain [14].
Physiological and rehabilitative interventions for pediatric chronic pain, including physical and
occupational therapy, focus on improving physical functioning by progressively engaging children in
previously avoided activities and taking a self-management approach to pain [16,17]. The goal of these
12
J. Clin. Med. 2019, 8, 1267
interventions is to improve strength, flexibility, endurance, joint stability, tolerance for weight-bearing,
coordination, balance, and proprioception [5,18–20]. Because the goal of these therapies is to promote
independence (i.e., ability to manage daily life without excessive support from parents and caregivers)
and a return to functioning (e.g., return to school and sport), active interventions (e.g., exercise) have
a more significant role than passive interventions (e.g., massage or transcutaneous electrical nerve
stimulation (TENS)) [21]. The goals of physical and occupational therapeutic interventions are often
focused on independent functioning, as well as improved coping and increased self-efficacy, as opposed
to pain reduction [22,23]. Following a thorough assessment within a biopsychosocial framework,
including an assessment of functional goals, a developmentally-appropriate and individualized
therapeutic treatment plan is developed and implemented [24]. The following section thoroughly
reviews the evidence of effectiveness of the aforementioned rehabilitative treatments across outpatient,
as well as intensive outpatient and inpatient treatment programs (see Table 1).
Table 1. Best Evidence for Rehabilitation in Pediatric Chronic Pain.
Evidence Supporting Interventions Examples of Resources

Individual Outpatient Interventions
Tame the Beast
What is Pain? The Mysterious Science of
Heathcote et al., 2019 ** [25]; Moseley & Butler [26],
Pain Science Education Pain
2015; Pas et al., 2018 [27] *
PNE4Kids
A Journey to Learn About Pain
Physiological Self-Regulation
Eccleston et al., 2002 [28] **
Training
Benore and Banez, 2013 [29]; McKenna et al., Breathe2Relax
Biofeedback
2015 [30] * BellyBio
Progressive Muscle Relaxation Palermo, 2012 [10] Progressive Muscle Relaxation Script
Liossi et al., 2003 [31]; Tome-Pires & Miro,
Self-Hypnosis
2012 [32];
Guided Imagery Van Tilburg et al., 2009 [33] *
Mindfulness-based Stress Evans et al., 2010 [34]; Jastrowski Mano et al.,
Reduction (MBSR) and Yoga 2013 [35] *
Eccleston et al., 2015 [36] **; Fisher et al.,
Cognitive Skills Training
2014 [14] **; Palermo et al., 2010 [15] **
Kanstrup et al., 2017 [37]; Kemani et al., 2018 [24];
Behavioral Exposure
Wicksell et al., 2007 [38] *; Wicksell et al., 2009 [39]
Cognitive Behavioral Therapy for iSleep App
Palermo et al., 2017 [40] *
Insomnia (CBT-I) CBT-I App
Conquering Your Child’s Chronic Pain
Managing Your Child’s Chronic Pain
Parent Coaching Eccleston et al., 2014 [36] **; Palermo, 2012 [10] When Your Child Hurts
Pain in Children and Young Adults: The
Journey Back to Normal
Problem-Solving Skills Training Law et al., 2017 [41]; Palermo et al., 2016 [42] *
Multi-component Treatment
Packages
Cognitive-Behavioral Therapy for
Eccleston et al., 2014 [36] **; Fisher et al.,
Cognitive-Behavioral Therapy Chronic Pain in Children and
2014 [14] **; Palermo et al., 2010 [15] **
Adolescents
Acceptance and Mindfulness Treatments
Acceptance and Commitment Therapy Pielech et al., 2017 [43]; Wicksell et al., 2009 [39]
for Children and Adolescents
Physical Therapy
Strength and Endurance Eccleston and Eccleston, 2004 [44]; Kempert et al.,
Training 2017b [45]; Mirek et al., 2019 [46]
Gait and Posture Training
Occupational Therapy
Independence with Activities of Daily
Kempert et al., 2017a [47]; Kempert et al., 2017b [45]
Living
Desensitization Sherry et al., 1999 [48]
13
J. Clin. Med. 2019, 8, 1267
Table 1. Cont.
Evidence Supporting Interventions Examples of Resources

Interdisciplinary Outpatient Pain
Treatment
Kashikar-Zuck et al., 2018 [49] *; Tran et al.,
FIT Teens
2016 [50] *
2B Active Dekker et al., 2016 [51]
GET Living GET Living, NCT: 03699007
Intensive Interdisciplinary Pain
Hechler et al., 2015 [19] **
Treatment (IIPT)
Emerging Pain Treatment
Intervention Formats
One-day workshops Coakley et al., 2018 [52] The Comfort Ability
Bonnert et al., 2019 [53]; Palermo et al., 2018 [54];
Internet and mobile applications
Stinson et al., 2014 [55]
Virtual Reality Won et al., 2015 [56] *; Won et al., 2017 [57]
Note: Tame the Beast and What is Pain? The Mysterious Science of Pain videos were not specifically developed for
children. * denotes pilot studies; ** denotes systematic review and/or meta-analysis. All other studies listed are
individual clinical trials or topical reviews.
2.1. Pain Related Education

The goal of psychoeducation is to provide the child and family with an explanation of the
differences between acute and chronic pain and to emphasize the non-protective nature of chronic
pain [12]. Psychoeducation is typically guided by the biopsychosocial model [4] and is an important
component of treatment as it provides the family with a rationale as to how psychological interventions
can be effective in addressing pain and associated disability [12]. Although psychoeducation is
typically embedded in any comprehensive cognitive-behavioral treatment package, the clinicians
and researchers in the field of physiotherapy have delved deeper into educating patients about pain
science as a therapeutic tool and have worked to test the efficacy of pain science education both as a
specific treatment component [26,58], as well as in combination with other biopsychosocially-oriented
treatment components [59–61] Indeed, adding a cognition-targeted active approach to pain science
(e.g., progression to the next phase of education is preceded by an intermediate phase of imagery or
work on cognitions that might hinder progression) is considered critical in achieving larger long-term
therapy effects, given that pain science as a stand-alone treatment only demonstrates small to medium
effect sizes [62,63]. Although already used in clinical practice worldwide, research on pain science
education in the pediatric pain field is just beginning.
Pain Science Education

“Pain science education”, also called “pain neuroscience education” [63,64], “therapeutic
neuroscience education” [65,66], or “explaining pain” [26], aims to change one’s conceptual
understanding of pain [67]. To enhance rehabilitation treatments, pain science education provides
a foundation for understanding principles that guide biopsychosocial interventions for persistent
pain [35]. Pain science education teaches people about the underlying biopsychosocial mechanisms of
pain, including how the brain produces pain and that pain is often present without, or disproportionate
to, tissue damage. In more complex and persistent pain states, this also includes peripheral and central
sensitization, facilitation and inhibition, neuroplasticity, immune and endocrine changes [58]. Evidence
shows that understanding pain decreases its threat value which, in turn, leads to more effective pain
coping strategies [61,68]. Given that children with chronic pain often have significant problems with
functioning (e.g., more school absenteeism and lower participation in daily, after-school, and family
activities) contributing to lower quality of life, less physical fitness, and eventually more pain [69], pain
science education may prepare and prime children with chronic pain for biopsychosocial treatments.
Pain science education is commonly part of multidisciplinary pain treatment [70] and can utilize
freely available online resources [25] that complement pain science education/communication which is
typically individually-tailored and thereby primarily delivered by a therapist. Additionally, PNE4Kids,
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a pain science curriculum for children (6–12 years old), has recently been developed [27] and is freely
available for clinicians at http://www.paininmotion.be/pne4kids. Although there is meta-analytic
evidence for adults suggesting that pain science education improves outcomes [71], evidence in
pediatric chronic pain is scarce but promising with Andias et al. [72] providing support of a combined
approach (pain science education + exercise therapy) in adolescents with chronic idiopathic neck pain,
with data showing that this type of intervention is feasible and beneficial in pediatric patients with
chronic pain. Yet, some methodological shortcomings were present in this study, such as the rather
small sample size (n = 43) and the control group who did not receive any treatment (nor attention from
the therapists). Therefore, further methodologically sound research is needed to assess both conceptual
and behavioral change in relation to pain science education.
2.2. Physiological Self-Regulation Training

An often recommended intervention for children with chronic pain is training in self-regulation of
physiological responses to pain (e.g., heart rate, breathing rate, skin temperature, and muscle tension).
Relaxation-based strategies typically include deep-breathing exercises, progressive muscle relaxation,
and imagery [10]. Studies have shown the direct benefits of relaxation techniques for children with
persistent pain including slowing of heart rate and breathing, increased blood flow to the muscles, and
decreased muscle tension e.g., [73]. These bodily changes have also been found to reduce the experience
of stress and anxiety [74]. Often used in conjunction with relaxation training, biofeedback provides
real-time feedback to the child related to the physiological processes and changes (e.g., changes in
heart rate or skin temperature) that occur in the body when engaging in aforementioned relaxation
techniques [29]. There is also some evidence for self-hypnosis. Several studies highlight the utility of
self-hypnosis with pediatric procedural pain [30,31] and there is some evidence that it may be helpful
with chronic conditions as well [32]. Examining a sample of 300 children with functional abdominal
pain, Anbar [75] found that 80% of patients demonstrated improvement in pain following a course of
self-hypnosis. Another study examined the efficacy of self-hypnosis in 26 children with chronic pain.
Results demonstrated that self-hypnosis was significantly associated with decreased pain intensity, as
well as improvements in functioning across academic and social domains and sleep [76].
Mindfulness-Based Stress Reduction and Yoga

Mindfulness-based stress reduction (MBSR) involves teaching patients mindfulness and focuses
on bringing attention to the present moment, with the thought that shifting attention to the present
allows for the use of positive coping strategies [77]. Data from pilot trials demonstrates evidence for
the efficacy of MBSR for reduction of pain and stress, with improvements maintained at 6-month
follow-up [35,78]. Additionally, there is some evidence for the role of yoga [34] and massage [79,80] in
treating pediatric chronic pain. Integrating aspects of MBSR and yoga might help enhance interventions
delivered within this population.
2.3. Cognitive Skills Training

Cognitive skills training focuses on the identification of negative and maladaptive
thoughts/cognitions with the goal of systematically reframing and changing these thoughts [81].
Several clinical trials have demonstrated that children with chronic pain benefit from cognitive skills
training [15]. Cognitive techniques such as cognitive restructuring, problem-solving, and positive
self-talk, have been shown to be effective techniques for reducing negative thoughts associated with
pain and related disability [10,13,14].
Incorporating components of Acceptance and Commitment Therapy (ACT) [82,83] into treatment
may be beneficial, and there is evidence to suggest that ACT can be effective for children with chronic
pain [39,84]. ACT focuses on increasing psychological flexibility and engagement in valued activities
(e.g., willingness to go to school or to a friend’s house even if pain is present) [82,85]. ACT differs
from traditional cognitive therapy in that it focuses on changing the relationship the child has with
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distressing and negative thoughts as opposed to changing the thoughts themselves. This is done
through exercises focused on cognitive defusion, which aims to increase the child’s ability to notice the
thought and how it influences behavior, rather than changing the content of the thought [86]. One
study examining acceptance and values-based treatment for adolescents with chronic pain found
that adolescents improved in self-reported functioning, as well as on objective measures of physical
performance and reported a decrease in anxiety and catastrophizing [84] following intervention.
Additionally, Wicksell and colleagues [85] examined mediators of change in ACT and found that ACT
worked through improvements in processes related to psychological flexibility rather than through
changes in traditional CBT constructs, providing additional evidence that ACT may be functionally
different from traditional cognitive-behavioral treatments.
2.4. Behavioral Exposure

Operant-behavioral theories have long been applied to chronic pain populations to understand the
association between pain severity and pain-related disability [87,88]. The Fear Avoidance Model [89,90]
describes how heightened fear of pain and continued avoidance of activities that might exacerbate
pain leads to prolonged disability, and recent work has focused on pain-related fear in children
and adolescents and the application of the Fear Avoidance Model of Chronic Pain within pediatric
patients [91,92]. Exposure-based treatments for pediatric chronic pain aim to improve functioning by
exposing patients to activities they are currently avoiding due to fear of pain. In a study examining
the efficacy of behavioral exposure within an ACT framework for children and adolescents with
chronic pain, results demonstrated greater reductions in pain severity, functional disability, and fear
of pain for patients who received the exposure treatment compared to those who received standard
multidisciplinary treatment [39].
Graded in-vivo exposure, a treatment typically delivered by a psychologist and physio or
occupational therapist [93,94], thus considered an interdisciplinary outpatient treatment, is now being
evaluated in children and adolescents with chronic pain (described further in the Interdisciplinary
Outpatient Pain Treatment section) [51]. The first single case experimental design (SCED) trial of
graded in-vivo exposure in youth demonstrated robust improvements in pain-related avoidance
and pain intensity with increased activity engagement at the end of treatment with decreases in
pain-related fear and catastrophizing observed at 3-month follow-up with improvements across
outcomes maintained at 6-month follow-up (Simons et al., [95]). Additionally, work has been done
to incorporate interoceptive components, which involve having the child imagine increases in pain
severity, into exposure treatments for children with chronic pain [96,97]. Use of interoceptive exposure
techniques have been associated with decreased pain intensity and school avoidance, and data suggest
that using these techniques are beneficial at reducing pain severity and altering relevant emotions
related to pain [96].
2.5. Parent Coaching

While the aforementioned interventions often consider the child to be the primary treatment target,
parents play a critical role in managing pain and maintaining or improving functioning [10]. At the
very basic level, parents are often taught the relaxation and cognitive skills along with the child so that
they are better able to help their child carry out the interventions at home [10]. Treatment with parents
also focuses on shifting parent attention and behavioral responding toward encouraging function in
the presence of persistent pain, while coaching the child to use coping skills to support functioning
(i.e., contingency management). Findings from a systematic review of parent–child interventions,
including cognitive-behavioral and family-focused treatments, found that these interventions could
be beneficial in improving parent behaviors, e.g., reducing attention to pain symptoms, encourage
functioning despite pain [36].
There is also evidence to suggest that parents of children with chronic pain experience significant
emotional distress related to their child’s pain (e.g., [98]). Recent work has been done to adapt
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problem-solving skills training (PSST), which teaches parents structured approaches to solving
problems and targets parent distress, with results demonstrating that psychological interventions
focused on reducing parent distress were effective [41,42]. Furthermore, a recent review [99] found
that psychological interventions also improved parent mental health across a chronic illness sample,
including parents of children with chronic pain. These findings support the notion that parent distress
impacts child functioning [100]. Therefore, it is critical to consider parent distress when working with
this population, as accurate assessment and treatment of parent distress, in addition to behavioral
functioning, may have important implications for child outcomes. Additionally, there are several books
written for parents that provide support and instruction on how to implement the aforementioned
strategies and support coping and functioning in their children [44,101–103].
2.6. Physical Therapy

When working with children and adolescents with chronic pain, the key objectives of a physical
therapist include encouraging the adoption of regular exercise, facilitating repeated exposure to
movement in the presence of pain, and educating families regarding misconceptions about anatomy,
physiology, pain, exercise and activity [48]. To assist the child in achieving functional goals, physical
therapy works to improve strength, flexibility, endurance, joint stability, tolerance for weight-bearing,
coordination, balance, and proprioception [5,18–20].
Exercise is a crucial component of rehabilitation for children and adolescents with chronic pain [7]
and there are data to suggest that earlier experience with exercise is associated with better adherence [9].
Exercise activities for pain in the lower extremities may focus on jumping, fast-paced walking and/or
running, climbing stairs, balance and coordination activities, and age-appropriate physical education
activities and sport drills, whereas upper extremity exercises typically focus on strengthening and
coordination drills [104]. It is important that exercises occur in a variety of settings, such as in the
gym with equipment, at home without equipment, in a pool, or out in public settings, to assist with
generalization of skills and reduce site-specific exercise behavior [105]. It is also important to take a
behavioral management approach when increasing physical activity, most often achieved through
gradual exposure to activities and pacing, which involves increasing intensity gradually as tolerance
builds [19,48].
2.7. Occupational Therapy

Another vital component of rehabilitation for chronic pain is occupational therapy [8].
Occupational therapy differs from physical therapy in that the focus of interventions are on
maximizing independence in age-appropriate activities of daily living and self-care (e.g., bathing,
dressing, grooming), as well as academic (e.g., handwriting) and family activities (e.g., participation
in chores) [17,19,48]. These goals are often achieved through individualized strategies such as
psychoeducation, participation in games (e.g., standing up while playing a board game, or participating
in games that requiring reaching or bending-designed based on patients functional goals), sensory
discrimination, and developing a daily schedule to support engagement in meaningful activities
throughout the day [5,8,106]. Desensitization, a technique used to reduce physical sensitivity to certain
stimuli, is another important intervention provided though occupational therapy, particularly for
patients with central pain sensitization (e.g., Complex Regional Pain Syndrome; CRPS) who experience
difficulties tolerating physical stimulations and sensations on affected areas of the body. These patients
may guard or protect the sensitive area in an attempt to avoid it being touched. In severe cases,
patients may be unable to tolerate pressure from clothing items, such as socks, shoes, and tighter pants.
To address this, the occupational therapist engages the patient in desensitization exercises, which may
include rubbing the sensitive area with various textures including tissue, feather, textured fabrics, and
towels, to gradually expose the nervous system to different sensations with the goal of retraining the
brain to process these stimulations more typically [104].
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An early meta-analytic review [107] found that conventional (i.e., monodisciplinary) physical and
occupational therapy are better than no treatment or only medical treatment. There are also data to
suggest that for specific conditions, such as CRPS, early individualized intensive physical therapy
is considered best [108,109]. However, monodisciplinary rehabilitation treatments have been found
to be inferior to multidisciplinary and interdisciplinary treatment approaches, where physical and
occupation therapy are combined with psychological intervention [19,107].
2.8. Addressing Comorbidities

Sleep is an important aspect of health and development in childhood and adolescence.
Unfortunately, disturbances to sleep, including insomnia and delayed sleep phase, are prevalent in
children with chronic pain [110] and are associated with negative emotional, cognitive, and behavioral
consequences [111]. Thus, thorough assessment of sleep and sleep hygiene (i.e., habits that might
affect sleep onset or maintenance throughout the night, such as consumption of caffeine, spending too
much time during the day in bed, use of electronics at bedtime) is warranted [10]. There is evidence to
suggest psychological interventions are effective at addressing sleep problems. Specifically, cognitive
behavioral therapy for insomnia (CBT-I) has been found to be effective for adolescents with co-occurring
physical and psychological conditions, including adolescents with chronic pain [40]. Outcomes from
the pilot trial demonstrated improvements in insomnia, as well as improvements in sleep quality and
sleep hygiene, psychological symptoms, and overall health-related quality of life [40].
Additionally, chronic pain is often associated with comorbid psychiatric concerns including
depression, anxiety disorders, and post-traumatic stress disorder (PTSD) [112] and the co-occurrence
is likely bidirectional in nature. In other words, psychological symptoms could potentially be a
contributing factor and an outcome of having chronic pain [33,113]. Additionally, there are data to
suggest that chronic pain is a risk factor for suicidal ideation in adolescents, and clinicians should
be alert to suicidal ideation and/or attempt within the population [114]. Consultation with and
involvement of psychiatric care should be incorporated into treatment when appropriate. Further,
assessing for adverse childhood events, trauma, or maltreatment may also be important and exposure
to early childhood adversity may hinder the ability to effectively implement interventions. In addition
to depression and anxiety, the presence of neurological and/or neuropsychiatric symptoms (e.g.,
conversion disorder) co-occur in pediatric pain populations [115]. Effective interventions need to target
co-morbid mental health disorders and identify underlying mechanisms that serve to maintain mental
health and pain conditions.
2.9. Interdisciplinary Outpatient Pain Treatment

Over the last several years, effort has been made to examination the efficacy of interdisciplinary
interventions delivered at the outpatient level. Fibromyalgia Integrative Training for Teens (FIT Teens)
combines cognitive-behavioral interventions with neuromuscular exercise training [49]. Results from
the pilot randomized controlled trial (RCT) comparing FIT Teens to CBT-only demonstrated that
adolescents who participated in FIT Teens experienced significant improvements in disability and
greater decreases in pain intensity compared to the CBT-only condition, suggesting that FIT Teens
provides additional benefits above and beyond CBT for children and adolescents with fibromyalgia.
Additionally, there are several emerging interventions focusing on graded in-vivo exposure therapy
(GET) for children and adolescents with chronic pain [51]; (GET Living, NCT: 03699007). One ongoing
randomized controlled trial (RCT) in the Netherlands, “2B Active”, combines GET and physical therapy
to increase functioning by having patients complete activity exposures [51]. Additionally, there is an
ongoing RCT in the United States comparing GET Living to multidisciplinary pain management in
children with chronic pain (GET Living, NCT: 03699007). Similar to 2B Active, GET Living utilizes a
psychologist and a physical therapist to deliver exposure interventions. However, different from 2B
Active, GET Living specifically targets pain-related fear and avoidance.
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2.10. Intensive Interdisciplinary Pain Treatment

Often when patients are unsuccessful at outpatient treatments, a more intensive, interdisciplinary
pain treatment (IIPT) is required [19]. There is evidence from a systematic review and meta-analysis
to suggest that IIPT may be effective at reducing disability and maintaining this reduction after
treatment for a subgroup of patients [19]. Specifically, children and adolescents have demonstrated
improvements in pain intensity, pain-related disability, and symptoms of depression post-treatment,
with improvements maintained at 3-month follow-up. To be considered an IIPT program, the program
includes three or more disciplines housed within the same facility (e.g., pain specialist, psychologist,
and physical therapist) who work in an integrated manner to provide treatment in a day hospital or an
inpatient setting. IIPT programs can be day treatment or inpatient and typically require the patient to
participate in exercise-based therapies (PT and OT) as well as psychological interventions, for a total of
eight hours per day [19].
Eccleston and colleagues [116] were the first to examine the effectiveness of intensive
interdisciplinary pain treatment. The program examined was a 3-week multidisciplinary treatment
for patients and parents, with results demonstrating immediate improvements in functioning. After
a 3-month follow-up, data showed a significant decrease in anxiety, pain catastrophizing, disability,
and improvements in school attendance. Another study compared a 3–4 week intensive day hospital
rehabilitation program with standard outpatient treatments, which included various combinations
of medical treatment, psychological, and physical therapies [117]. While there were improvements
noted across both treatment groups, patients enrolled in the intensive day rehabilitation program
had significantly larger improvements in functional disability, pain-related fear, and willingness to
adopt a self-management approach to treating pain [117]. A recent study [5] examined the effects
of an intensive day treatment program in which patients completed 1–2 half day sessions per week
(lasting approximately 4 h each) for 4–8 weeks. Results indicated improvements in pain severity, as
well as physical and psychological functioning [5]. To date, there has only been one randomized
control trial (RCT) comparing intensive interdisciplinary pain treatment (IIPT) to a waitlist control
group [106]. The IIPT utilized in this trial was a manualized program consisting of 6 treatment
modules including pain psychoeducation, pain coping skills, cognitive intervention to target emotional
distress, family therapy, physiotherapy, and parent sessions. Immediate effects were achieved for
pain-related disability, school attendance, depression, and catastrophizing, with pain intensity and
anxiety decreasing at 6-month follow up [106]. These results are consistent with outcomes from other
intensive interdisciplinary pain rehabilitation treatment centers [108,118].
While all IIPT programs share the primary goal of improved functioning across domains, there
is variability across programs with regard to structure, organization, and frequency of treatment
delivery across disciplines [8]. One major distinction is that of intensive outpatient and inpatient
treatment models. In comparing outcomes reported from intensive outpatient [108] and inpatient
programs [118,119], patients in each program demonstrate significant functional improvements. Of
note, several intensive pain rehabilitation programs offer both inpatient and day hospital programs,
with patients triaged to level of care based on individual needs [17]. To our knowledge, outcomes
between levels of care within the same facility have yet to be published. Another difference between
intensive pain programs includes length of stay. For example, some programs have a fixed, 3-week
length of stay, while others have a more flexible length of stay which is often established based on
individual patient needs. Despite these differences, significant functional improvements are reported
for these treatment programs. Continued examination of outcomes within and between treatment
programs is warranted, as is further examination of mechanisms of change for patients undergoing
IIPT treatment.
A recent study conducted a cost-analysis of an interdisciplinary pediatric pain clinic by
retrospectively reviewing billing data for inpatient admissions, emergency department, and outpatient
visits and associated costs and reimbursements [120]. Data examined included healthcare costs for
patients 1 year prior to initiating interdisciplinary services with costs 1 year after initiating services.
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Cost-analyses of pre-pain clinic costs found cost reductions 1 year post clinic participation (up to
$36,228 to the hospital and $11,482 to insurance, per patient, per year), providing economic support for
interdisciplinary intervention for children with chronic pain [120].
2.11. Emerging Pain Treatment Intervention Formats

One-day workshops. One day group-based psychological interventions for children with chronic
pain have inherent benefits as it allows children and adolescents to meet peers with similar struggles
and allows them to receive social support and benefit from shared experiences. These workshop
programs can also be cost and time effective. One such program, The Comfort Ability [52] in an
intensive one-day intervention, delivered concurrently to children and their parents, that introduces
cognitive-behavioral skills of pain management and helps families develop a plan to support functional
improvement. The workshop is currently available across 15 children’s hospitals in the United States
and Canada. Preliminary evaluation of this workshop demonstrates improvements in child functioning,
depressive symptoms, and pain catastrophizing, which persist at 1-month follow-up. Additionally,
parents report improvements in responses to their child’s pain and beliefs regarding their child’s ability
to manage pain [52].
Internet and mobile applications. Recently, effort has been made to address access barriers for
pediatric pain management services. Palermo and colleagues developed an 8-week online psychological
intervention for children and their parents (WebMAP). Online modules included relaxation training,
cognitive strategies, parent operant techniques, communication strategies, and interventions focused
on sleep and activity engagement. Pilot data demonstrated that internet-delivered pain management
reduced barriers of access to care and was effective at reducing pain-related disability [121]. The
program was further developed into a mobile app version with data also indicating greater reduction
in pain intensity and functional disability post treatment compared to waitlist control [54]. Other
mobile-based technologies have been developed to assist patients in remotely self-monitoring symptoms
and deliver interventions involving goal-setting for improving functioning, coping skills training and
practice, and social support via discussion boards, goal sharing, and group-based challenges [55].
Additionally, an ACT based digital intervention for individuals with chronic pain has recently been
developed in a series of studies with desktop as well as mobile use [122]. Results from an RCT with
adults (n = 113) showed moderate to large effects in primary and secondary outcomes, with effects
remaining 12 months following the end of treatment. Additionally, a review examining remotely
delivered psychological therapies found that they were beneficial at reducing pain intensity across pain
groups [123]. While these programs allow for patients to have access to treatment, remotely-delivered
interventions may not be appropriate for all patients, and more complex patients would likely benefit
from more intensive treatments.
Augmented reality and virtual reality. Augmented reality and virtual reality (VR) have been
found to be an effective tool for reducing pain sensations in patients with acute pain [56,57,124].
One recent study examined the effects of VR in patients with chronic right arm pain secondary to a
diagnosis of complex regional pain syndrome (CRPS), type 1. Similar to results found within acute and
procedural pain samples, Matamala-Gomez and colleagues [125] found that multisensory interventions
that manipulated body from VR modulated pain perceptions. Continued research on the effectiveness
of VR within the pain rehabilitation setting is needed and should be a focus of future research within
this population.
2.12. Summary of Rehabilitative Treatments for Pediatric Chronic Pain

In sum, rehabilitation for pediatric chronic pain applies the biopsychosocial model, which takes
into account the complex interplay of biological, psychological, social, and environmental factors that
contribute to and maintain pain and related disability. Given all of the domains impacted by pain,
rehabilitation typically require a comprehensive and multidisciplinary approach. Currently, there is
strong evidence to support early, targeted, treatments, with most rehabilitative interventions including
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pain education, psychological interventions, and physical and occupational therapies. Promising
directions for clinical practice and research are discussed below.
3. Promising Directions for Clinical Practice

Given the expansive growth of rehabilitation interventions for youth with chronic pain, it is
imperative to match individual patients with the appropriate treatment modality and level of intensity.
The use of a screening tool, such as the Pediatric Pain Screening Tool (PPST) [126] could potentially
be used to facilitate efficient treatment allocation. PPST is a 9-item screening tool used to identify
prognostic factors (e.g., sleep disturbance, depression, anxiety) associated with adverse outcomes,
with allocation to the high-risk group based upon responses to psychosocial items. The PPST can be
easily delivered within a busy clinical setting and allows providers to quickly and effectively identify
medium to high risk youth who may benefit from access to more comprehensive, multidisciplinary
treatments [126]. Administering the PPST would allow patients to be triaged to the appropriate level
of care, without having to trial treatments that might not be appropriate given their level of risk. For
example, a patient who screens medium to high risk could be triaged to initiate both psychology and
physical therapy, whereas a low-risk patient might benefit from physical therapy alone. Efforts to
better match individual patients with specific treatments might help to reduce “treatment failure” that
some patients experience when they engage in treatments that poorly match their current symptoms
and functioning (e.g., the need for CBT-I for sleep difficulties).
Further, attempts to tailor the interventions delivered within each discipline might also be
beneficial. For example, when a patient is triaged to psychology for pain management, extra effort
should be made by the provider to assess what specific treatment modality might be most beneficial.
For example, a patient with musculoskeletal pain who is experiencing high pain-related fear and
avoidance may benefit from including a more targeted graded exposure treatment approach, as
opposed to solely focusing on historically popular components of cognitive-behavioral interventions
for chronic pain (e.g., relaxation skills training). Lastly, continued effort should be made address
barriers to access of care and continued effort should be made to integrate one-day workshops that
can be delivered on the weekends e.g., the Comfort Ability [52], as well as internet-based and mobile
application treatments [54,55]. See Figure 1 for visual overview.
Figure 1. Schematic overview of Potential Future Directions for Clinical Practice. PPST = Pediatric
Pain Screening Tool; PT = Physical Therapy; Psych = Psychology; MD = Medical Doctor; OT =
Occupational Therapist.
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4. Promising Directions for Research

Future research should focus on establishing clinical cut-off’s for measures assessing core outcome
domains, as this will allow for better evaluation of clinically significant change post-treatment. Along
these lines, it will be important to explore emerging treatment targets (e.g., assessing pain-related
fear and avoidance vs. pain catastrophizing vs. functional disability, pre/post treatment). It will also
be important to continue to examine innovative and targeted multidisciplinary treatments. Over
the last several years, effort has been made to develop interdisciplinary outpatient treatments, such
as FIT Teens [49], 2B Active [51], and GET Living (NCT: 03699007), and preliminary outcomes are
promising [51].
There is also a need to explore the processes and mechanisms of change within pain rehabilitation
programs. In doing this, effort should be made to support collaboration between multiple disciplines
involved in pediatric pain rehabilitation (e.g., psychology, physical therapy, occupation therapy, pain
medicine). It may be also beneficial to establish standard pain program protocols, such as the one
presented by Maynard, Amari, Wieczorek, Christensen and Slifer [118]. The use of a uniform protocol
across IIPT programs would also allow for further examination of the mechanisms within these
programs that account for the significant functional improvements these patients experience.
Examining outcomes across levels of care will also be important. Future randomized controlled
trials should focus on examining outcomes between intensive day treatment and inpatient treatment.
Such a trial might allow researchers to better understand what treatment works for whom, and
why. Examination of outcomes across treatment settings would allow for further examination of the
most efficient and cost-effective way to deliver empirically supported treatment to children and their
families. Lastly, continued examination of outcomes for e-Health is also warranted. In addition to
providing services to patients in low-resource areas, mobile- and internet-delivered programs for pain
management could be used to supplement in person treatments as patients complete more intensive
rehabilitation services and transition back into social and academic environments.
5. Conclusions
In conclusion, chronic pain is a prevalent and persistent problem in childhood and adolescence.
Rehabilitation for pediatric chronic pain is typically based on learning theory and on the biopsychosocial
model of pain, which accounts for the complex interplay of the biological, psychological, social, and
environmental factors that contribute to and maintain pain symptoms and related disability. Given
all of the systems involved and effected by chronic pain, the treatment of chronic pain requires
comprehensive treatment approaches, including psychological intervention, physical therapy, and
occupational therapy. With the emergence of several targeted interventions to address the individual
challenges each patient with chronic pain faces coupled with new means of overcoming barriers to
access, the field is well-positioned to alleviate the suffering of youth with chronic pain and reduce their
risk of transitioning to adults with chronic pain.
Key Messages
1. Comprehensive multidisciplinary and interdisciplinary treatment based on behavioral medicine
approaches are needed for children and adolescents with persistent pain.
2. Pain Science Education is commonly implemented with several resources currently available, yet
evidence for its use is scarce.
3. Unique to pediatric rehabilitative approaches is the emphasis on including parents to optimize
treatment outcomes.
4. Innovative pain treatment intervention formats such as mobile applications and virtual reality
enhance the delivery and reach of evidence-based tools.
5. Comprehensive multidisciplinary/interdisciplinary treatment based on contemporary
understanding of pain (neuro) science are needed for children and adolescents with persistent pain.
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Author Contributions: Conceptualization, L.E.S., R.K.W., L.E.H., J.W.P., and K.I.; methodology, L.E.S., L.E.H.,
J.W.P., and K.I.; investigation, L.E.H. and J.W.P.; data curation, L.E.H. and J.W.P.; writing—original draft preparation,
L.E.H., J.W.P., R.K.W., P.A.R., and K.I.; writing—review and editing, L.E.H., J.W.P., L.E.S., R.K.W., P.A.R., and K.I.;
supervision, L.E.S. and R.K.W.; funding acquisition, L.E.S.
Funding: This research was funded by NIAMS/R21AR072921.
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29
Journal of
Clinical Medicine
Review
Best-Evidence Rehabilitation for Chronic Pain Part 2:
Pain during and after Cancer Treatment
An De Groef 1,2, *,† , Frauke Penen 1,2 , Lore Dams 1,2 , Elien Van der Gucht 1,2 , Jo Nijs 3,4 and
Mira Meeus 2,5
1 Department of Rehabilitation Sciences, KU Leuven, University of Leuven, Herestraat 49,
3000 Leuven, Belgium
2 Department of Rehabilitation Sciences and Physiotherapy, MOVANT, University of Antwerp,
Universiteitsplein 1, 2610 Antwerp, Belgium
Anatomy (KIMA), Faculty of Physical Education & Physiotherapy, Vrije Universiteit Brussel (VUB),
Laarbeeklaan 103, 1090 Brussels, Belgium
4 Department of Physical Medicine and Physiotherapy, University Hospital Brussels, Laarbeeklaan 101,
5 Pain in Motion International Research Group, Department of Rehabilitation Sciences, Faculty of Medicine
and Health Sciences, Ghent University, De Pintelaan 185, 9000 Ghent, Belgium
* Correspondence: an.degroef@kuleuven.be; Tel.: +32-16-342-171
† Support statement: ADG is a post-doctoral research fellow of the FWO-Flanders.
Received: 5 June 2019; Accepted: 4 July 2019; Published: 5 July 2019
Abstract: Pain during, and especially after, cancer remains underestimated and undertreated.
Moreover, both patients and health care providers are not aware of potential benefits of rehabilitation
strategies for the management of pain during and following cancer treatment. In this paper, we
firstly provided a state-of-the-art overview of the best evidence rehabilitation modalities for patients
having (persistent) pain during and following cancer treatment, including educational interventions,
specific exercise therapies, manual therapies, general exercise therapies and mind-body exercise
therapies. Secondly, the findings were summarized from a clinical perspective and discussed from
a scientific perspective. In conclusion, best evidence suggests that general exercise therapy has
small pain-relieving effects. Supporting evidence for mind-body exercise therapy is available only in
breast cancer patients. At this moment, there is a lack of high-quality evidence to support the use of
specific exercises and manual therapy at the affected region for pain relief during and after cancer
treatment. No clinically relevant results were found in favor of educational interventions restricted to
a biomedical approach of pain. To increase available evidence these rehabilitation modalities should
be applied according to, and within, a multidisciplinary biopsychosocial pain management approach.
Larger, well-designed clinical trials tailored to the origin of pain and with proper evaluation of
pain-related functioning and the patient’s pain experience are needed.
Keywords: cancer; pain; rehabilitation; exercise
1. Introduction
Since both prevalence and survival rates of cancer continue to rise, an increasing number of people
have to cope with the debilitating effects of this disease and its treatment. Pain is one the most prevalent
and persistent problems reported by cancer patients and survivors [1,2]. A recent meta-analysis
reported prevalence rates of 55% during cancer treatment and 40% after curative treatment [3]. Pain can
interfere with activities of daily life, quality of life and fulfillment of a person’s role in society. Yet,
pain during, and especially after, cancer remains underestimated and undertreated [4].

J. Clin. Med. 2019, 8, 979
Nowadays, pharmacological treatment is considered the standard approach for treating pain
related to cancer (treatment) [5,6]. However, both patients and health care providers are often not aware
of other possible rehabilitation strategies and their potential benefits in the management of pain during
and after cancer treatment [5,7]. Cancer rehabilitation includes a multidisciplinary and biopsychosocial
approach which aims to optimize functioning, well-being and participation of cancer survivors in
general, as well as pain relief specifically [7,8]. An important role in the multidisciplinary team is
reserved for the physical therapist, at all levels of cancer care (inpatient versus outpatient) and across the
whole continuum of complexity of a patient’s pain complaint [8]. Traditional rehabilitation modalities
for pain during and following cancer treatment consist of both general (including mind-body exercises)
and specific exercises as well as manual techniques to restore physical functioning. Additionally,
awareness of the added value of educational interventions in a rehabilitation session has increased
substantially and these interventions can no longer be ignored [9,10]. While literature on the beneficial
effects of rehabilitation on physical symptoms (such as fatigue, exercise capacity) and general quality
of life in cancer patients or survivors is overwhelming, evidence for pain relief in particular is rather
scarce in this population.
In this paper, we firstly provided a state-of-the-art overview of the best evidence rehabilitation
modalities for patients having (persistent) pain during and following cancer treatment. Secondly,
the findings were summarized from a clinical perspective to facilitate integration from research into
daily clinical practice. At last, the state-of-the-art overview was discussed from a scientific perspective.
This way, future clinical researchers can build upon this best evidence when designing future trials,
implementation studies or new innovative therapies.
2. State-of-the-Art
For this paper, we have identified scientific studies using broad search terms including ‘pain’,
‘cancer’ and ‘rehabilitation’ in MEDLINE (PubMed), SCOPUS and Pedro. To minimize selection bias
and ensure the selection of high-quality evidence, systematic reviews and meta-analyses were preferred
when possible. For the scope of this paper, evidence on rehabilitation modalities for pain during and
following cancer was summarized in five categories, being educational interventions, specific exercise
therapies, manual therapies, general exercise therapies and mind-body exercise therapies. The focus
was limited to cancer patients and survivors with a primary cancer diagnosis and pain during and/or
after active cancer treatment. Rehabilitation of advanced and metastatic cancers did not belong to the
scope of this paper. Details on the target population, rehabilitation modality, comparator, pain-related
outcomes, rehabilitation setting, rehabilitation providers and conclusions regarding the pain-related
outcomes can be found in Table 1.
2.1. Education
In general, patient education interventions can be defined as “the process by which health
professionals and others impart information to patients that will alter their health behaviors or improve
their health status” [11].
32
Table 1. Detailed best evidence table.
Rehabilitation Rehabilitation
Author, Year (Design) Target Population Rehabilitation Modality Comparator Pain-Related Outcomes Conclusion
Setting Providers
1. Education
Oldenmenger et al. 2018 - adults Educational intervention: Usual care or active - pain intensity (NRS or VAS) Outpatient and (Oncology) nurse, stat. sign. differences in favour of
(Systematic review of RCTs) - solid malignancies information, behavioural control intervention - pain interference (Brief Pain inpatient research education were found for:
- cancer-related pain instructions + advice (by Inventory or an equivalent) assistant/nurse - pain intensity in 31% of studies
verbal, written, audio- or - knowledge about cancer-related pain, - pain interference in 33% of studies
J. Clin. Med. 2019, 8, 979
videotaped or pain barriers (Barriers Questionnaire) (only evaluated in 40% of included RCTs)
computer-aided modalities) - medication adherence (Medication - pain knowledge or barriers in 68% of
Adherence Scale, Medication Event studies (only evaluated in 84% of
Monitoring System or self-report) included RCTs)
- medication adherence in 50% of
studies (only evaluated in 23% of
included RCTs)
Prevost et al. 2016 - adults Patient educational programs Usual care, general - pain intensity (NRS) Ambulatory, home (Oncology) nurse stat. sign. differences in favour of
(systematic review of - cancer patients with pain (PEP): information, patient education, - pain interference (Brief Pain care, and hospital education were found for:
(non-) RCTs behavioural instructions + nutrition education Inventory or an equivalent) settings - pain intensity in 52% of studies
advice (by verbal, written, - knowledge about cancer-related pain, - pain interference in 12% of studies
audio- or videotaped, pain barriers (Barriers Questionnaire) (only evaluated in 37% of included RCTs)
telecare, or computer-aided - medication adherence (questionnaires - pain knowledge and barriers in 81%
modalities) or self-reported) of studies (only evaluated in 70% of
included RCTs)
- medication adherence in 45% of
studies (only evaluated in 25% of
included RCTs)
33
Ling et al. 2012 (review - adults Educational intervention: Non-educational - pain intensity (Brief Pain Inventory, Outpatient Healthcare staff - 50% of studies reported stat. sign.
of RCTs) - cancer-related pain information, behavioural treatment, no Total Pain Quality Management) decrease in pain intensity
instructions and advice by treatment or usual - pain interference (Brief Pain - no stat. sign. results for pain
means of verbal, written or care Inventory, Total Pain Quality interference
audio/video-tape messages Management)
Table 1. Cont.
Setting Providers
2. Specific exercise therapy
McNeely et al. 2010 - female adults 1) Active or active-assisted 1) Early (day 1–3 - pain incidence Outpatient and Physical therapist, 1) Early vs. delayed post-operative
(review + meta-analysis - breast cancer patients who ROM exercises; post-surgery) vs. - pain intensity (VAS) inpatient manual therapist, exercises:
of RCTs) had surgical removal of 2) Passive ROM/manual delayed (day 4 or occupational - no stat. sign. difference in pain
breast tumour, axillary stretching exercises; later post-surgery) therapist or exercise incidence at 2w, 1Mo, 6Mo and 2y FU
J. Clin. Med. 2019, 8, 979
lymph node dissection or 3) Stretching exercises 2) usual specialist (Bendz et al 2002) and 3Mo FU
sentinel node biopsy (including formal exercise care/comparison (Le Vu 1997)
- during and after cancer interventions such as yoga 3) supervised vs. 2) Specific exercises vs. usual
treatment and Tai Chi Chuan); unsupervised care/comparison
4) Strengthening or resistance - no stat. sign. difference in pain
exercises. incidence post-intervention (OR: 1.65;
Carried out following 95% CI: 2.50 to 0.81) or at 6Mo FU (OR:
surgery, during adjuvant 1.51; 95% CI: 2.35 to 0.67) (Beurskens et
treatment and following al 2007)
cancer treatment - stat. sign. different decrease in pain
intensity: −3.4 vs. −0.5 (p < 0.01) at
3Mo; −3.8 vs. −1.0 (p > 0.05) at 6Mo
(Beurskens et al 2007)
3) Supervised vs. unsupervised
- no stat. sign. difference in pain
intensity post-intervention (MD: −5.40
points; CI: −19.16 to 8.36)
(Hwang et al 2008)
34
De Groef et al. 2015 - female adults- breast cancer Active exercises 1) Early (day 1–3 - pain incidence Outpatient NS 1) Early vs. delayed
(review of (pseudo-) RCTs) - maximum of 6 weeks post-surgery) vs. - pain intensity (NRS or VAS) post-operative exercises:
postoperative delayed (day 4 or - no stat. sign. differences for pain
later post-surgery) intensity (reported in only one study,
2) usual Bendz et al 2002)
care/comparison/no 2) Specific exercises vs. usual care
exercise program - no stat. sign. difference in pain
incidence post-intervention (OR: 1.65;
95% CI: 2.50 to 0.81) or at 6Mo FU (OR:
1.51; 95% CI: 2.35 to 0.67) (Beurskens et
al 2007)
- stat. sign. different decrease in pain
intensity: −3.4 vs. −0.5 (p < 0.01) at
3Mo; −3.8 vs. −1.0 (p > 0.05) at 6Mo
(Beurskens et al 2007)
Table 1. Cont.
Setting Providers
Carvalho et al. 2012 - adults 1) Active or active-assisted No treatment, usual - pain subscale of the Shoulder Pain Inpatient: Cross NS - stat. sign. beneficial effects for
(review + meta-analyses - head and neck cancer range of motion exercises care, placebo, sham and Disability Index (SPADI) (0–100) Cancer Institute and Progressive Strengthening Training (12
of RCTs) - during and after cancer 2) Passive range of exercises or University of weeks) compared to standard care for
treatment motion exercises pharmacological Alberta in pain subscale of the SPADI; MD −6.26
- with dysfunction of the 3) Stretching exercises interventions Edmonton, Canada 95% CI (12.20 to −0.31)
J. Clin. Med. 2019, 8, 979
shoulder due to having 4) Resistance exercises (McNeely et al 2004

received any type of cancer 5) Proprioceptive and 2008)
treatment neuromuscular facilitation
6) Any other exercise with a
focus on shoulder
dysfunction treatment or
prevention, whether
combined or not with
pharmacological
intervention.
3. Manual therapy
De Groef et al. 2015 - female adults- breast cancer Passive mobilizations 1) Early (day 1–3 - pain incidence Outpatient NS - pain or sensitivity problems: 74% in
(review of (pseudo-) RCTs) - max 6 weeks postoperative. post-surgery) vs. - pain intensity (NRS or VAS) no physical therapy vs. 70%
delayed (day 4 or mobilisation group vs. 72% massage
later post-surgery) groups vs. 68% mobilisation and
2) Usual massage group at 3 Mo (p > 0.05)
care/comparison/no - locoregional pain: 5% in mobilization
exercise program group vs. 13% in no mobilization
35
group (p = 0.03) at 8–24 Mo Follow-Up
(Le Vu et al., 1997)
Shin et al. 2016 (review + - adults and children Massage therapy: tissue No massage - pain intensity (NRS, VRS or VAS) Outpatient Trained therapists - massage
meta-analyses of RCTs) - metastatic, colorectal, manipulation using a carrier and inpatient or not mentioned significant effect in 1/5 studies on
advanced, breast, lung, oil or blended carrier oil with present pain intensity (NRS 0–10): MD
paediatric and non-specified essential oils (i.e., −1.60, 95% CI (−2.67 to −0.53)
cancer aromatherapy); excluding
touch therapies such as
therapeutic touch,
acupressure, and reflexology.
Boyd et al. 2016 (review + - adults Massage therapy: the Sham, no treatment, - pain intensity/severity (VAS) Inpatient, at Massage therapist, - 79% (11/14) of studies showed
meta-analyses of RCTs) - metastatic, colorectal, systematic manipulation of or active comparator patient’s or unspecified significant beneficial effects of massage
advanced, breast, paediatric soft tissue with the hands (i.e., participants are therapist’s home or therapist, nurse, therapy on pain intensity
and non-specified cancer that positively affects and actively a hospice healing-arts - meta-analysis massage vs. no treatment
- with pain promotes healing, reduces receiving any type of specialist, caregiver, including 3 studies: SMD= −0.20, 95%
stress, enhances muscle intervention) or a researcher CI (−0.99 to 0.59); reduction in pain
relaxation, improves local trained in massage intensity = −5.075, 95% CI (−24.80
circulation, and creates a to 14.63)
sense of well-being. - meta-analysis massage vs. active
comparator including 6 studies:
SMD = −0.55, 95% CI (−1.23 to 0.14);
reduction in pain intensity = −13.63,
95% CI (−30.78 to 3.5)
Table 1. Cont.
Setting Providers
4. General exercise therapy
Nakano et al. 2018 - adults 1) Aerobic exercise program Not receiving any - EORTC-QLQ-C30 – pain symptom NS NS - overall effect of exercise on
(SR and meta-analyses - during and after 2) Resistance (major) exercise subscale EORTC-QLQ-C30 – pain symptom
of RCTs cancer treatment exercise program intervention or other subscale: SMD −0.17, 95% CI (−0.32 to
3) Mixed exercise program interventions (e.g., −0.03); p = .02;
J. Clin. Med. 2019, 8, 979
cognitive behavioural - no stat. sign. difference among 3

therapy); groups with subgroups:
only attention, 1) aerobic exercise program (4 studies):
relaxation, or NS
education 2) resistance exercise program (3
studies): NS
3) mixed exercise program (4 studies):
SMD −0.28; 95% CI (−0.47 to −0.09); p
= .005
Mishra et al. 2012 (SR and - adults Exercise interventions and No exercise, another - pain intensity (EORTC-QLQ-C30 – NS NS - pain intensity: −0.29 95% CI (−0. 55
meta-analyses of RCTs - after cancer treatment (i.e., any physical activity causing intervention, or usual pain symptom subscale or Shoulder to −0.04) standard deviation units after
and CCTs) survivors) an increase in energy care (e.g., with no Pain and Disability Index (SPADI)) 12 weeks follow-up; (4 studies)
- excluding those who are expenditure, and involving a specific exercise A standard deviation unit is equivalent to
terminally ill and receiving planned or structured program prescribed) about a 28-point change on the QLQ-C30
hospice care movement of the body pain sub-scale
performed in a systematic
manner in terms of frequency,
intensity, and duration and is
36
designed to maintain or
enhance health-related
outcomes
Mishra et al. 2012 (SR and - adults Exercise interventions and No exercise, another - Pain intensity (MOS SF-36 – pain Individual or group, Professionally led or - no significant effect was obtained
meta-analyses of RCTs - during active cancer any physical activity causing intervention, or usual subscale, EORTC QLQ-C30 – pain home or facility not when pooling
and CCTs) treatment an increase in energy care (e.g., with no symptom subscale, VAS, MD based trials that reported change in pain
- excluding those who are expenditure, and involving a specific exercise Anderson Symptom Inventory - pain from baseline to follow-up nor overall
terminally ill and receiving planned or structured program prescribed) subscale) pain for follow-up values
hospice care movement of the body
performed in a systematic
manner in terms of frequency,
intensity, and duration and is
designed to maintain or
enhance health-related
outcomes
Table 1. Cont.
Setting Providers
5. Mind-body therapy
Pinto-Carral et al. 2018 (SR - adults Pilates exercises: focused on Other exercise - Pain intensity (Brief Pain Inventory, NS Specialized pilates - stat. sign effect for pain intensity:
and meta-analyses of RCTs - breast cancer core muscle strengthening, interventions VAS) centres (outpatient) SMD −0.48; 95% CI (−0.88 to −0.07)
and CCTs) - during and after cancer spine flexibility and shoulder or at home
treatment girdle range of motion
J. Clin. Med. 2019, 8, 979
Danhauer et al 2019 - adults Yoga: multicomponent Waitlist, usual care or - Pain (not further specified) NS NS - 1/1 study stat. sign. improvement of
(SR of RCTs) - breast, prostate, lymphoma protocols (i.e., active comparator pain during cancer treatment
colorectal or mixed cancer movement/postures, - 2/3 studies stat. sign. improvement of
groups breathing and mediation) pain after cancer treatment
- during and after cancer based on several different
treatment yoga types (Anusara,
Eischens, Iyengar, Tibetan,
Bali, Vivekananda Yoga
Anusandhana Samsthana)
Pan et al. 2015 - adults Tai Chi Chuan (NS) Psychosocial therapy - pain (not specified health-related NS NS - no stat. sign. effect for pain: SMD
(SR and MA of RCT) - breast cancer intervention, quality of life questionnaire or SF-36) 0.11; 95% CI (−0.41 to 0.18)
- after active cancer treatment standard care, health
education
Stat. sign. = Statistically Significant; RCT = Randomized Controlled Trial; SR = Systematic Review; NRS = Numeric Rating Scale; VAS = Visual Analogue Scale; VRS = Verbal Rating
Scale; SMD = Standardized Mean Difference; MD = Mean Difference; CI = Confidence Interval; Mo = Months; w = weeks; y = years; EORTC-QLQ-C30 = European Organization for
Research and Treatment of Cancer Quality of Life Questionnaire-C30; MOS SF-36 = Medical Outcome Study 36-Item Short From Survey; NS = Not specified.
37
J. Clin. Med. 2019, 8, 979
In the broad field of rehabilitation, the importance of education has increased tremendously over
the past years, especially in patients with musculoskeletal pain [12]. In the oncological field, several
reviews have summarized the effectiveness of educational interventions on pain intensity, the use of
analgesics, side effects and misconceptions on opioids, in patients with pain from active cancer [13–17].
Within the rehabilitation scope of this paper, we found three systematic reviews that had summarized
the effectiveness of an educational intervention in the form of individual information, behavioral
instructions and advice in relation to management of pain related to cancer (treatment) [16–18] (Table 1,
Section 1. Education). Comparing educational interventions with usual care, they had found a
statistically significant difference in pain intensity in 31% [17], 50% [18] and 52% [16] of the included
studies, respectively. Up to 33% [17] and 12% [16] of included studies also showed significant beneficial
effects on pain interference with daily activities. Interestingly, Prevost et al. (2016) found that 81% of
the studies had significantly improved knowledge and beliefs regarding pain and 45% of studies had
improvement in adherence with prescribed analgesics in the education group [16]. In the review of
Oldenmenger et al., 68% of the studies showed a significant difference in pain knowledge or barriers,
including poor knowledge and misconceptions about pain medication and their side-effects. This last
one also evaluated medication adherence and found a statistically significant increase in the education
group in 50% of studies [17].
However, these studies could neither find a relation between pain knowledge/barriers and
pain intensity, nor medication adherence among the included trials reporting both outcomes [17].
Few studies reported effect sizes and despite their significance, these effect sizes were small and
of limited clinical relevance in all included studies [18]. Also, response rates are low with only an
improvement in pain in 20% of all included patients in the review of Oldenmenger et al [17].
A possible explanation for these rather limited beneficial effects may be the narrow scope of the
educational interventions. Indeed, the content of the educational interventions can vary widely among
studies and can have different scopes. The emphasis of the educational interventions in these reviews
was restricted to a biomedical approach of pain. This is illustrated by the fact that most education
was given by (oncology) nurses and medical doctors and mainly covered the consequences of cancer
treatment and the pharmacological and medical management of these sequellae. However, considering
the increased knowledge of pain pathophysiology, education should additionally incorporate a more
biopsychosocial explanation of pain [10], as this has been supported by research in various other
chronic musculoskeletal pain populations. This modern educational approach has a broader scope
and aims at removing barriers for all aspects of pain management (including self-management
and rehabilitation). It targets the patient’s cognitions and knowledge of pain as well as his/her
pain-related behavior and thereby aims for a shift from a passive therapy-receiver to an active
self-manager [9,10,16,17]. Additionally, education may vary in type (face-to-face, leaflet, video),
provider and duration. Furthermore, populations and mechanisms of pain in the included studies were
quite heterogeneous, making it unclear whether pain was related to active cancer and/or a consequence
of cancer treatment modalities [14,16].
All things concerned, although the effect of educational interventions in a rehabilitation setting
seems promising, the ambiguity of its essential components when applied in a cancer population still
remains to be further unraveled.
2.2. Specific Exercise Therapy

Specific exercise therapy typically includes active and/or active-assisted strengthening, mobilizing
and stretching exercises to restore function of the affected region [19]. The literature on the effectiveness
of specific exercise for pain in cancer survivors is scarce [20]. A tremendous amount of research
has been done on the effect of specific exercises for other upper limb dysfunctions during and after
head, neck and breast cancer. Range of motion, upper limb strength and upper limb function in
general may be affected after surgery and radiotherapy due to formation of fibrosis and scar tissue,
nerve damage, muscle tightness, lymphedema (including axillary cording) and pain [20–22]. Specific
38
J. Clin. Med. 2019, 8, 979
exercises are indeed prescribed to optimize and/or restore joint and muscle function of the affected
region. Reduction in pain is often presumed to occur subsequently. However, pain might be a primary
indication for specific exercises as well. In particular, for nociceptive and neuropathic pain at the
affected region, specific exercises may aid in increased blood flow, as well as a reduced hyperesthesia,
inflammation, biomechanical deficits and muscle spasms [5,23,24]. To our knowledge, only four
systematic reviews have summarized randomized controlled trials on the effectiveness of specific
exercises in an oncological population that included pain outcome measures [19–21,25] (Table 1, Section
2. Specific exercise therapy).
First, in breast cancer patients, three reviews have summarized the effectiveness of different
exercise programs compared to usual care or no exercises [19,20,25]. The exercise programs varied in
content (mobilization, stretching, strengthening and stabilization exercises) and in duration (timing,
frequency and intensity). For (shoulder) pain, with the exception of one study, no differences between
two groups were found. This study compared active exercises with a leaflet and showed beneficial
effects on pain intensity on a visual analogue scale (0–10) three months (−2.7 95% CI (−3.6 to −1.9)) and
six months (−2.5 95% CI (−3.5 to −1.6)) following surgery [26]. Remarkably, almost all studies reported
beneficial effects of exercises on shoulder range of motion and/or shoulder function in general.
Additionally, several studies showed no difference in an early or delayed start of specific exercises
after surgery for pain incidence and pain intensity up to two years follow-up [19,20]. Comparing a
supervised versus non-supervised program [27], differences in neither pain incidence nor intensity
were found [19].
Another Cochrane review and meta-analysis (including two studies) in patients treated for head
and neck cancer pain showed significant beneficial effects of a progressive strengthening training
program on pain [21]. However, results were not clinically relevant.
In conclusion, there is currently no evidence available that supports the use of specific exercise
therapy for relieving pain in cancer patients or cancer survivors. Several reasons for this can be
postulated. First, these exercise programs were designed to increase physical impairments, including
impaired range of motion and strength, and pain was only considered as a secondary outcome.
The latter implies that the available trials were not designed to examine the potential for specific
exercises on pain relief (i.e., the trials might have been underpowered to detect clinically important
changes in pain; the trials included all cancer patients or cancer survivors, while not all patients
suffer from clinically relevant levels of pain, in turn decreasing the ability of a treatment to generate
important changes). Moreover, most studies only evaluated pain intensity. Other dimensions of pain,
or rather pain-related disability, are outcomes of higher clinical relevance and may reflect true effects
of specific exercise interventions. Lastly, the underlying mechanism of the patients’ pain complaint
was not taken into account when providing the exercise therapy to the patients suffering from cancer
or post-cancer pain. Pain during and after cancer treatment can have many origins with different
associated indications for exercise therapy. Therefore, prescription guidelines on specific exercises
for pain after cancer treatment are not available and it remains to be established which type(s) of
exercise therapy (strengthening, mobilizing and stretching exercises) is indicated depending on the
predominant pain mechanism at different time points throughout cancer treatment and thereafter.
The most important message from the limited amount of research is that specific exercises
are safe. However, evidence on the best type of exercise, the exact modalities and timing is
inconclusive [19–21,25].
2.3. Manual Therapy

Within the cancer field, studies of manual therapy address passive joint mobilizations and massage
therapy. First, manual passive mobilizations primarily aim at restoring joint range of motion trough
alleviating capsular restrictions, distracting (soft) tissues and providing movement and lubrication
for normal articular cartilage. Additionally, pain relief may be achieved through the activation of
mechanoreceptors and stimulation of fast-conducting fibers [28]. The review of De Groef et al. included
39
J. Clin. Med. 2019, 8, 979
one RCT on the effectiveness of passive mobilizations after breast cancer surgery [20] (Table 1, Section 3.
Manual Therapy). This study indicated beneficial effects of passive mobilizations during the first week
post-surgery on long-term prevalence of locoregional pain. However, this one study shows high risk
of bias, so results are inconclusive [29].
Second, research on massage therapy in cancer population on the other hand is overwhelming.
Massage can be defined as the manipulation of the soft tissues of the body, performed by the hands,
for the purpose of producing effects on the vascular, muscular, and nervous systems [30]. Two most
recent systematic reviews of RCTs are discussed here (Table 1, Section 3. Manual Therapy). A Cochrane
review on massage, including 19 studies of which 5 reported the effects on pain, showed beneficial
effects of massage therapy in only one study [31]. Another review found beneficial effects of massage
in 79% of the included studies [32]. However, beneficial effects on pain intensity were very small and
of limited clinical relevance as illustrated by the meta-analyses: Standardized Mean Difference (SMD)
of −0.20 (95% CI, −0.99 to 0.59) for massage versus no treatment and SMD of −0.55 (95% CI, −1.23 to
0.14) for massage versus an active comparator (including attention, usual care, standard treatment,
a reading group comparator, and caring presence) [32]. The review indeed concluded in the evidence
synthesis that only weak recommendations can be made for massage therapy and that effects are
clinically irrelevant [32]. As suggested by the definition of massage therapy, other effects aimed at with
massage therapy may be a reduction in anxiety and stress and an enhancement of personal sense of
well-being through the effect on body and mind [32]. However, the studies in both reviews were of
very low quality and included a mix of primary, advanced, and metastatic cancers; concluding that
there is a lack of clear evidence to support the use of massage for pain relief in people with cancer at
this moment [31,32].
2.4. General Exercise Therapy

Exercise can be defined as “any physical activity causing an increase in energy expenditure,
and involving a planned or structured movement of the body performed in a systematic manner in
terms of frequency, intensity, and duration and is designed to maintain or enhance health-related
outcomes” (American College of Sports Medicine). Typically, aerobic and resistance training are
considered when discussing general exercise therapy [33,34]. A systematic review of systematic reviews
by Stout et al. summarized results of 53 reviews on exercise in cancer populations [35]. They concluded
that exercise was beneficial before, during, and after cancer treatment, across all cancer types, and
for a wide range of physical outcome parameters. Moreover, exercise was found to be safe during
all cancer stages. Several reviews in different cancer populations indeed confirmed the beneficial
effect of exercise on quality of life [36–38]. Despite this large amount of studies and clear guidelines,
no recommendations for using general exercise therapy for the treatment of pain in cancer populations
were extracted.
Frist, Nakano et al. published the most recent meta-analysis limited to RCTs using the
European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-C30
(EORTC-QLQ-C30) [39] (Table 1, Section 4. General exercise therapy). They summarized the effect of
aerobic and/or general resistance exercises on physical symptoms, including pain, for cancer patients
and survivors in any setting. The meta-analysis showed that pain in the intervention group (receiving
aerobic and/or resistance exercises) was significantly lower compared to no intervention. However,
the effect size was only small (SMD of −0.17 (95%CI, −0.32 to 0.03)) and no differences among the
3 types of exercises interventions could be extracted [39]. Second, two Cochrane reviews of Mishra et
al. summarized the effectiveness of exercise interventions on health-related quality of life, including
pain, during active cancer treatment [34] and in cancer survivors [33], respectively (Table 1, Section 4.
General exercise therapy). During active cancer treatment, no significant effects for pain relief in favor
of general exercises were described. In cancer survivors, pooled data of four studies showed beneficial
effects of exercise for pain with a small effect size (SMD of −0.29 (95% CI, −0. 55 to −0.04)). Another
noteworthy Cochrane review summarized the beneficial effects of general physical activity, including
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activities as part of occupation, active transportation, household and gardening chores, and recreational
activities [40]. Exercise was considered as a subcategory of physical activity. This review showed
beneficial effects for a wide range of health-related outcome parameters. For pain however, 9 out of the
63 included trials that reported a pain outcome measurement showed no beneficial effects [40].
These reviews summarized the effectiveness of aerobic and/or resistance exercise therapy as an
intervention [33,34,39,40]. The type of exercise therapy and specific modality most efficient for pain
relief was not clear. In the general population, exercise is considered very important in pain management
because of its possible beneficial effect on central pain (inhibitory) mechanisms, the autonomic nervous
system, the immune system (anti-inflammatory effect) and subsequent hypoalgesic effect [41–43].
However, the response to exercise is more variable in chronic musculoskeletal pain populations and
may even result in hyperalgesia [41–43]. For cancer populations, even less is known about pain
processing during and after exercise therapy, and a possible impaired analgesic response to exercise
(therapy) and physical activity. Remarkably, in particular for hormone therapy related arthralgia,
which is experienced by up to 50% breast cancer survivors treated with aromatase inhibitors, general
exercise therapy holds high value [44–46]. Findings from a high-quality randomized controlled trial
indicated that 150 minutes per week of aerobic exercise and supervised strength training twice per
week can lead to clinically relevant improvements in pain [46].
In conclusion, general exercise therapy is safe and well tolerated, both during and after cancer
treatment. However, only limited evidence is available on the beneficial effects for pain relief during
and after cancer treatment in general. The exact exercise modalities to ensure this pain relief are
not described [33,34,39]. However, a combination of aerobic training and strengthening exercises is
recommended for pain relief in patients with hormone therapy related arthralgia [46].
2.5. Mind-Body Exercise Therapy

Mind-body exercises intend to enhance the mind’s capacity to positively affect bodily functions
and symptoms, including pain, by combining exercises with mental focus [47]. They have gained
interest in many fields of rehabilitation, including cancer.
First, pilates has found its way into many rehabilitation practices. One review showed that pilates
was statistically more effective than the interventions in the control groups for reducing pain among
women with breast cancer, showing a moderate effect (SMD of −0.48 (95%CI, −0.88 to −0.07)) [48]
(Table 1, Section 5. Mind-body therapy). However, only women with breast cancer were included.
Yoga is becoming very popular in cancer rehabilitation as well, as reflected by the 29 RCTs summarized
in the review of Danhauer et al. [49] (Table 1, Section 5. Mind-body therapy). They reported
improvements in general quality of life, fatigue, and perceived stress. Pain was investigated only in a
very small number of studies showing inconclusive results [49]. Another popular type of mind-body
exercises is Tai Chi Chuan. However, for pain in breast cancer survivors, pooled results of three RCTs
could not demonstrate beneficial effects (SMD of 0.11 (95%CI, −0.41 to 0.18)) [50] (Table 1, Section 5.
Mind-body therapy).
The positive effect of mind-body therapies, in particular yoga in e.g., breast cancer patients,
seems more obvious for psychological wellbeing, including stress, anxiety and depression [47,49].
Similarly, for massage therapy, through a reduction in anxiety and stress and enhancement of personal
sense of well-being a relief in physical symptoms, including pain, may be achieved [32,47].
Mind-body exercise therapy are often considered as complementary therapeutic interventions and
may play an important role in cancer rehabilitation. While pilates seems to have clinically important
pain-relieving effects in women with breast cancer, evidence for yoga as a pain-relieving intervention
in cancer populations is inconclusive.

Both clinicians and researchers highlight and emphasize the tremendous need of a systematic
follow-up of side-effects related to cancer and its treatment(s), including pain, in order to improve
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quality of life of cancer survivors. Indeed, besides treatment of cancer itself and follow-up of relapses,
a systematic prospective care pathway is minimally required for each cancer patient [51–55]. The key
elements of such a care model are (1) a proactive approach to regularly examine and question patients
on pain and pain-related disability; (2) providing ongoing assessment during all stages of cancer
treatment (often in absence of problems) and (3) uniform efforts to enable early interventions for pain
management, including mono- and complex multidisciplinary interventions, both in inpatient and
outpatient settings [51–55].
A first step in improving clinical practice through clinical care pathways would be early detection
and proper diagnosis of pain in cancer. A clear diagnosis of a patient’s pain complaint is a critical
step in clinical decision-making. Over the past decades, knowledge on the origin of pain during and
after cancer treatment has increased [5,7]. From a tumor-related and a treatment-related classification
of pain, there was a major shift to a mechanism-based classification of cancer pain [56,57]. During
adjuvant treatment of a primary cancer, the tumour is removed, so it is expected that pain is no more
related to cancer, per se. In the early stage of cancer treatment, nociceptive and/or neuropathic pain
caused by surgery, radiotherapy and/or chemotherapy is present in most cases [24,58]. At this stage,
pain is related to tissue damage and if adequately managed, can be considered as a short-term side
effect. In a later stage, when these local effects of the different cancer treatment modalities should
have been healed, the initial causes of pain may be overshadowed by sensitization of the central
nervous system in a subgroup of cancer survivors [58–60]. In this case, pain is no longer related to
tissue damage and can be explained by enhanced processing of sensory input (sensitization) within
the peripheral and/or central nervous system and by altered pain modulation, leading to so called
central sensitization pain or nociplastic pain [61]. Specifically for the cancer population, it is important
to recognize that local tissue damage or peripheral mechanisms can continue to contribute to their
pain complaint for a long time after completion of acute treatment, together with other sustaining
psychosocial factors e.g., postmastectomy pain syndrome and chemotherapy-induced peripheral
neuropathy [5] or related to ongoing treatment modalities for several years such as arthralgia related
to hormonal therapy [62]. For effective pain management, identification of the predominant pain
mechanism is warranted. Clinical guidelines for the identification of the predominant pain mechanism
in cancer survivors are available, however not validated [58].
Secondly, through the clinical care pathway, referral for adequate pain management is
facilitated [51]. As summarized above, a tremendous amount of research is available on rehabilitation
modalities for a wide range of physical symptoms during and after cancer treatment. Despite its high
prevalence rates and high disabling impact, in many studies “pain” was not used as outcome measure.
Too often pain is considered as “being part of” cancer survivorship, resulting in minimal effort to
detect pain and referral for adequate treatment. Although research is limited, the reviews described
above point towards promising pain-relieving effects of rehabilitation modalities for pain management
during and after cancer treatment. However, effect sizes are only small to moderate and research is
limited to mostly breast cancer populations. Based on this, the following modalities can be carefully
recommended in general. Firstly, both at the start and during a rehabilitation program, the added value
of an educational intervention based on modern pain (neuro)science—including a biopsychosocial
explanation of pain—should be considered to remove barriers for rehabilitation and promote adequate
pain behavior and cognitions [10]. In particular, in patients with maladaptive pain beliefs and behavior,
an educational intervention is warranted to explain pain and how different therapy modalities can
potentially influence this. Correct interpretation of symptoms during treatment will facilitate shared
decision-making and further therapy adherence. Secondly, currently no evidence supports the
pain-relieving effect of specific exercises and mobilizations during and after cancer treatment. Whether
these rehabilitation modalities have a role in particular for acute nociceptive and neuropathic pain
related to joint and muscle dysfunctions at the affected region should be further investigated [20–22,24].
Thirdly, general exercise therapy may result in pain relief. However, more research is needed on the
modalities (type, frequency, intensity and duration) to increase effect sizes and ensure reduction in
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pain and/or pain-related disability and avoid pain flares after exercise [33,34,39]. Indeed, in a subgroup
of cancer survivors with predominant nociplastic pain, endogenous pain modulation may be impaired
and alter the response to both specific and general exercise therapy. However, it is important to note and
explain that rehabilitation interventions, including exercise therapy, are still safe both during and after
cancer treatment. In particular, for cancer survivors with hormone therapy related arthralgia, general
exercise therapy is recommended [46]. At last, mind-body interventions, including general exercises
such as yoga and pilates, might have a complementary role. However, besides the pain-relieving
effects of pilates in women with breast cancer, study results are inconclusive. It has been argued
that the pain-relieving effect occurs through a reduction in anxiety and stress and enhancement of
personal sense of well-being [32]. The evidence on the influence of various psychosocial and emotional
factors on the (persistence of) pain has increased past decades [9,63]. Especially in cancer populations,
the cancer diagnosis, treatment but also the fear of cancer reoccurrence can induce stress, depression
and anxiety among others [64]. As proposed for the educational interventions, a biopsychosocial
explanation of pain is necessary. Therefore, mind-body therapies fit within this approach and may be
valuable modalities to address pain and its psychosocial sustaining factors. The remark has to be made
to what extent these mind-body therapies belong to the rehabilitation domain. Other interventions,
e.g., mindfulness, mediation, acupuncture, . . . are often considered as complementary mind-body
interventions as well. However, since the element of bodily movement in these interventions is not
apparent, they are beyond the scope of this paper. Given the multiple cancer treatment modalities,
pain is often not the only side effect during and after cancer treatment. When initiating rehabilitation
modalities for pain, in particular exercise therapy, other comorbidities should be taken into account
when developing a treatment plan. Fatigue is often associated with pain and vice versa, and may
hamper regular performance of general exercise. Several cancer treatments have a toxic effect on the
cardiovascular system among others, leading to decreased exercise tolerance. When establishing an
exercise program, this has to be taken into account [65].
Pain management during and after cancer treatment is not restricted to pharmacological therapy
and rehabilitation interventions. Other disciplines should be part of the rehabilitation team and
multidisciplinary treatment should be provided if necessary. Increased stress, anxiety and sleep
disturbances have been described to interfere with pain and/or pain-related disability and therefore
should be addressed if necessary [9,66]. Social workers may be important to address problems with
participation in society [67]. Other lifestyle interventions, including nutrition, smoking and excess
alcohol consumption, have been proposed to improve cancer survivorship and quality of life and
therefore their role in pain relief should be considered as well [68].
Additionally, pioneering studies are emerging on the use of eHealth in the cancer population.
Applications for symptom monitoring, including cancer pain, are already available and show
promising results [17,69]. These applications may also increase the accessibility to educational
resources and self-management strategies [69]. A recent review confirmed that applications supporting
self-management improve pain and fatigue outcomes in cancer survivors [70]. In line with this,
telecoaching interventions may be of value to increase adherence to specific exercise programs [71]
and/or physical activity in general in cancer patients [72]. These technological highlights keep
manifesting, but researchers warn that high-quality studies are currently still ongoing and these
interventions should be developed and tested properly before being recommended [69].

Current state-of-the art rehabilitation for pain during and after cancer treatment is limited.
When positive pain-relieving effects for rehabilitation interventions are found, effect sizes are most
often small to moderate. Different explanations can be given for this. In clinical practice different
interventions are combined, which is an important strength of rehabilitation for pain, but unfortunately
hard to translate into research. Additionally, pain relief from a comparative intervention, standard
intervention or even no intervention may occur and result in small effect sizes as well. Typically,
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responders and non-responders can be identified in clinical trials, especially when the intervention is
not tailored to e.g., the predominant pain mechanism. This may result in overall small effect sizes at
group level. Therefore, a balance between a pragmatic approach and highly standardized conditions is
needed in research. In the following paragraph, items that should be considered in further research
are discussed.
Firstly, both from a clinical and scientific perspective, it is highly important to correctly diagnose
pain and identify the predominant pain mechanism of a patient’s pain complaint. Clinical guidelines
for this purpose are described, however not validated [58,73]. Several studies did not clearly describe
whether pain was related to cancer itself or whether it was a side effect of the different treatment
modalities. Pain can be a symptom of cancer. However, pain due to cancer often means it has already
metastasized. For this paper, the focus was limited to cancer patients and survivors with a primary
cancer diagnosis and pain during and/or after active cancer treatment, so it is expected that pain
is no more related to the cancer itself. In future studies, this should be specified when diagnosing
pain in cancer patients and survivors. Associated with this, due to the prolonged side effects of
certain treatment modalities, e.g., radiotherapy and hormone therapy, it is in many cases difficult
to distinguish whether a patient’s pain complaint is still related to local tissue damage (nociceptive
and/or neuropathic pain) or rather to altered pain processing in nociplastic pain without dominant
peripheral input. Studies on the effectiveness of rehabilitation modalities tailored to the predominant
pain mechanism might result in larger effect sizes [58,74].
Secondly, besides a proper diagnosis of a patient’s pain complaint in order to tailor rehabilitation
modalities, a comprehensive pain assessment is warranted. The Initiative on Methods, Measurement,
and Pain Assessment in Clinical Trials (IMMPACT) recommends six core outcome domains that should
be considered when designing clinical trials on pain management. These domains include: (1) different
dimensions of pain; (2) physical functioning; (3) emotional functioning; (4) participant ratings of
improvement and satisfaction with treatment; (5) symptoms and adverse events; and (6) participant
disposition [75]. Indeed, in order to unravel the concept of pain, outcomes should not be limited to the
impairment itself, but also include pain-related functioning. Moreover, it is argued that rehabilitation
modalities and other interventions should focus on improvement of daily functioning and pain-related
disability, which will ultimately lead to reductions in patient’s pain intensity (or at least the debilitating
nature of pain). On the other hand, generic outcome measures such as general quality of life may lack
responsiveness to detect (more subtle) changes in pain [16,75]. Additionally, various psychosocial
factors play an essential part in the pain experience and the degree to which someone perceives their
pain as disabling. The effect of rehabilitation interventions on psychosocial outcomes and possible
moderating and mediating role of these factors in response to treatment for pain during and after
cancer treatment should be explored in future studies. At last, to explore the duration of response
and sustainability of rehabilitation interventions for pain relief, an adequate follow-up period should
be provided.
Thirdly, besides the high burden for the patient in the first place, the socio-economic impact
of pain during and after cancer treatment should be investigated. The number of people with
long-term sick leave or reduced working hours after cancer continues to rise. Pain, low (perceived)
physical functioning and low self-efficacy are factors associated with delayed return to work [76,77].
Additionally, rehabilitation entails a substantial financial cost for the health care system. Increasing the
effectiveness of rehabilitation for pain may decrease the number of rehabilitation and costs associated
with other more expensive pain management strategies. Therefore, proper health- and socio-economic
analyses are needed to change practice.
Fourthly, technological developments in rehabilitation should not be ignored, as they may lead to
innovative treatment avenues for cancer survivors as well. For example, preliminary study results show
that effects of virtual and augmented reality for rehabilitation of phantom limb pain [78], (neuropathic)
pain related to multiple sclerosis [79] and spinal cord injury [80] and pain in children [81] are promising.
In cancer patients, it may be valuable to distract patients from pain, to increase motivation and
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participation with a better response to treatment as a result. This may be an interesting research topic
in the future.
At last, an overwhelming amount of evidence is available in certain cancer populations, e.g.,
breast cancer. More trials in other cancer populations, such as colon and gynecological cancers are
needed before any general recommendations can be given. Additionally, rehabilitation for pain in
advanced cancers, palliative settings and populations with social disparities may warrant a different
approach and thus needs further investigation.
5. Conclusions
While literature on the beneficial effects of rehabilitation modalities for symptoms such as fatigue,
exercise tolerance and general quality of life is overwhelming, evidence for pain relief during and after
cancer treatment is rather scarce. In conclusion, best evidence suggests that general exercise therapy
has small pain-relieving effects. Evidence for mind-body exercise therapy in breast cancer is promising
given the moderate effect size. At this moment, there is a lack of high-quality evidence to support
the use of specific exercises and manual therapy at the affected region for pain relief during and after
cancer treatment. No clinically relevant results were found for educational interventions restricted to a
biomedical approach of pain. To increase available evidence, these rehabilitation modalities should
be applied according to and within a multidisciplinary biopsychosocial pain management approach.
Larger, well-designed clinical trials tailored to the origin of pain and with proper evaluation including
pain-related functioning and other outcomes related the patient’s pain experience are needed.
6. Clinical Implications
• Rehabilitation modalities, including manual therapy, specific and general exercise therapy, are safe
and well tolerated during and after cancer.
• Evidence for pain relief is scarce but promising.
• Despite the unclarity of essential components of education to improve pain, its role in rehabilitation
during and after cancer may be crucial for pain relief.
• Mind-body interventions including e.g., pilates may be complementary.
7. Research Agenda
• Distinct prescription guidelines for specific and general exercise therapy according to the FITT
principles should be explored.
• Validated guidelines for the accurate identification of the predominant pain mechanism in cancer
are warranted.
• The effectiveness of rehabilitation tailored to the predominant pain mechanism should
be investigated.
Author Contributions: Conceptualization, A.D.G., M.M. and J.N.; Literature search and data extraction, A.D.G.,
F.P., L.D. and E.V.d.G.; Writing, Original Draft Preparation, A.D.G., F.P., L.D. and E.V.d.G.; Writing, Review &
Editing, J.N. and M.M.; Supervision, J.N. and M.M.
Funding: This work is partially funded by the Berekuyl Academy Chair, funded by the European College for
Lymphatic Therapy, the Netherlands, and awarded to Jo Nijs, Vrije Universiteit Brussel, Belgium.
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49
Journal of
Clinical Medicine
Article
Best Evidence Rehabilitation for Chronic Pain Part 3:
Low Back Pain
Anneleen Malfliet 1,2,3,4,5, *, Kelly Ickmans 1,2,3,4 , Eva Huysmans 1,2,3,4,6 , Iris Coppieters 2,3,4,5 ,
Ward Willaert 2,3,5 , Wouter Van Bogaert 2,3 , Emma Rheel 2,3,7 , Thomas Bilterys 2,3 ,
Paul Van Wilgen 2,3,8 and Jo Nijs 2,3,4, *
1 Research Foundation–Flanders (FWO), 1090 Brussels, Belgium
2 Department of Physiotherapy, Human Physiology and Anatomy (KIMA), Faculty of Physical Education &
Physiotherapy, Vrije Universiteit Brussel, 1090 Brussels, Belgium
3 Pain in Motion International Research Group, 1090 Brussels, Belgium
4 Department of Physical Medicine and Physiotherapy, University Hospital Brussels, Laarbeeklaan 101,
5 Department of Rehabilitation Sciences and Physiotherapy, Faculty of Medicine and Health Sciences,
Ghent University, 9000 Gent, Belgium
6 Department of Public Health (GEWE), Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel,
7 Department of Experimental-Clinical and Health Psychology, Ghent University, 9000 Ghent, Belgium
8 Transcare, Transdisciplinary Pain Management Centre, 9728 EE Groningen, The Netherlands
* Correspondence: anneleen.malfliet@vub.be (A.M.); Jo.Nijs@vub.be (J.N.)
Abstract: Chronic Low Back Pain (CLBP) is a major and highly prevalent health problem. Given
the high number of papers available, clinicians might be overwhelmed by the evidence on CLBP
management. Taking into account the scale and costs of CLBP, it is imperative that healthcare
professionals have access to up-to-date, evidence-based information to assist them in treatment
decision-making. Therefore, this paper provides a state-of-the-art overview of the best evidence
non-invasive rehabilitation for CLBP. Taking together up-to-date evidence from systematic reviews,
meta-analysis and available treatment guidelines, most physically inactive therapies should not be
considered for CLBP management, except for pain neuroscience education and spinal manipulative
therapy if combined with exercise therapy, with or without psychological therapy. Regarding active
therapy, back schools, sensory discrimination training, proprioceptive exercises, and sling exercises
should not be considered due to low-quality and/or conflicting evidence. Exercise interventions
on the other hand are recommended, but while all exercise modalities appear effective compared
to minimal/passive/conservative/no intervention, there is no evidence that some specific types of
exercises are superior to others. Therefore, we recommend choosing exercises in line with the patient’s
preferences and abilities. When exercise interventions are combined with a psychological component,
effects are better and maintain longer over time.
Keywords: pain neuroscience; musculoskeletal pain; rehabilitation medicine; physiotherapy; lifestyle
1. Introduction
Chronic Low Back Pain (CLBP) is a major health problem worldwide and prevalence numbers
have increased substantially in the past decades [1]. A global systematic review reports a linear
correlation between age and CLBP prevalence, more specifically, individuals aged between 20 and
59 have a CLBP prevalence of 19.6%, while the prevalence in older people is 25.4% [2]. Besides pain,
disability is reported very frequently. CLBP is a major contributor to the global disability burden,

J. Clin. Med. 2019, 8, 1063
and continues to be the leading cause of years lived with disability [3,4]. About half of the people
who experience LBP will seek care [5]. Given the high prevalence numbers of CLBP [2], this relates to
excessive direct and indirect health care costs as well as a major social and economic impact [6,7].
Current guidelines recommend non-pharmacological and non-invasive management, including
the advice to stay active, the use of patient education and exercise therapy [8]. Yet, given the high
number of treatment guidelines, systematic reviews and randomized controlled trials on CLBP
management, clinicians might be overwhelmed by the evidence available. Taking into account the
scale and costs of the CLBP problem, it is imperative that healthcare professionals involved in CLBP
management should have access to up-to-date, evidence-based information to assist them in treatment
decision-making. Therefore, this paper aims to endorse consistent best practice, to reduce unwarranted
variation and to diminish the use of low-value interventions in CLBP care.
Here, a state-of-the-art overview of the best evidence non-invasive rehabilitation for people
having CLBP is provided. The best evidence non-invasive rehabilitation is reviewed in a way that
clinicians can integrate the evidence into their daily clinical routine. In addition, the state-of-the-art
overview also serves clinical researchers to build upon the best evidence for designing future trials and
implementation studies, and to develop new innovative studies.
2. State of the Art

To cover the best evidence non-invasive rehabilitation, this section relies on systematic reviews
and meta-analyses primarily. A non-systematic search of the literature was performed in PubMed,
Web of Science and Google Scholar using the following search terms: rehabilitation, chronic low back
pain, chronic back pain, chronic lumbar pain, chronic lower back pain. When possible, we used
‘systematic review’, and ‘meta-analysis’ filters. Additionally, information from several international
clinical guidelines was retrieved and discussed.
Given the strong empirical support indicating that pain severity alone is not a robust predictor of
function and improvement, we will focus both on pain and function as outcomes for chronic low back
pain management [9,10].
2.1. Evidence from Systematic Reviews, and Meta-Analyses

A non-systematic search for evidence on non-invasive rehabilitation modalities for CLBP increases
the understanding that CLBP is not only a common health problem but is also highly investigated.
Unfortunately, many systematic reviews focus on LBP in general, and include both (sub)acute and
chronic LBP. When the results of both populations were merged together in a review and specific
conclusions for CLBP could not be identified, these papers were excluded from this overview. An
outline of the available systematic reviews and meta-analyses that focused solely on CLBP, or in which
CLBP results could be isolated, can be found in Table 1. If more than one systematic review was found
regarding a specific topic, priority was given to including a meta-analysis (if available) and/or the most
recent paper available.
The overview of evidence available from systematic review and meta-analyses is presented using
the subdivision based on physically ‘active’ and ‘inactive’ interventions. Yet, this subdivision is chosen
for practical reasons, and relies on whether an intervention requires the patient to be physically active
or not. Therefore, pain neuroscience education will be discussed as part of the physically inactive
interventions. Yet, we would like to stress that pain neuroscience education requires mental and
cognitive activity of the patient given the required interaction between patient and therapist.
52
Table 1. Best evidence table for non-invasive rehabilitation in people with chronic low back pain: evidence from systematic reviews and meta-analyses.
Mono-/Multi-/
Intervention and Recommended for Clinical
Author, Year LoE Main Outcomes and Results Transdisciplinary [Involved Remarks
Sample Practice?
Rehabilitation Professions]
Physically inactive interventions
Small samples, most
3 studies: ↓ pain after ultrasound compared to
Therapeutic ultrasound Not stated studies lack follow-up Lack of strong evidence for the use
Noori, 2019 [11] 1A placebo or exercise
J. Clin. Med. 2019, 8, 1063
(n = 333) [Not stated] period. of ultrasound (LoC 1)

3 studies: no effect
No meta-analyses.
Pain intensity: No significant effect
Kinesiotape (n = 627) Disability: Significant ↓ in Oswestry Disability Monodisciplinary Lack of evidence for the use of
Li, 2019 [12] 1A /
Meta-analysis Index, but not in Roland Morris Disability [Physiotherapist] kinesiotape (LoC 1)
Questionnaire
PNE alone: no significant change in pain, but
Pain Neuroscience significant ↓ in disability and kinesiophobia at Moderate quality evidence to use
Monodisciplinary
Education (PNE) short term compared to an alternative Heterogeneity in pain neuroscience education as
Wood, 2019 [13] 1A [Physiotherapist or general
(n = 615) intervention. outcome measures. adjunct to usual physiotherapy
practitioners]
Meta-analysis PNE combined with other PT interventions: (LoC 1)
significant ↓ in pain at short-term.
Transcutaneous Similar conclusion in
Pain: Significant reduction during therapy, but not
electrical nerve other meta-analysis on
53
immediately after therapy or at 1 or 3mo Not stated Not recommended to use for CLBP
Resende, 2018 [14] 1A stimulation (TENS) effects of TENS on
follow-up. [Not stated] (LoC 1)
(n = 575) chronic back pain (Wu,
Disability: No effect during, or after therapy.
Meta-analysis 2018) [15]
Compared to inactive control: Massage may be
Subacute and CLBP
more effective for pain and disability at short
results are presented as
Massage (n = 2548) term. Conclusions at long term are unclear. Not stated Massage is not recommended to
Furlan, 2015 [16] 1A one group.
Meta-analysis Compared to active control: Results are unclear, [Not stated] treat CLBP (LoC 1)
Very low quality of
no conclusions can be made at short-and
evidence.
long-term follow-up.
Only two studies
Osteopathic Similar effect of osteopathic intervention when Monodisciplinary Not recommended due to lack of
Orrock, 2013 [17] 1A available.
intervention (n = 330) compared to sham intervention or exercise and PT. [Osteopath] evidence (LoC 1)
No meta-analysis.
Table 1. Cont.
Mono-/Multi-/
Sample Practice?
Pain: Moderate evidence that spinal manipulative
therapy provides statistically better results than
other interventions (exercise, PT, back school, Possible adjunctive therapy.
Spinal manipulative medical care) at 6mo, but not at 1 and 12mo Monodisciplinary Produces similar effects to
J. Clin. Med. 2019, 8, 1063
Rubinstein, 2019 Many studies with high

1A therapy (n = 9211) follow-up. [Physiotherapist, chiropractor, recommended therapies.
[18] risk of bias.
Meta-analysis Function: Moderate quality evidence that spinal manual therapist, osteopath] Possibility of adverse events. (LoC
manipulative therapy provides a small, 1)
statistically better result than other interventions
at 1mo, but not at 6 or 12mo follow-up.
Physically active interventions
Compared to PT alone: Pain: mixed results,
significant ↓ in 5 out of 10 studies; Disability:
mixed results, significant ↓ in 4 out of 7 studies;
Adding Cognitive Mono- or multidisciplinary
Hajihasani, 2019 Quality of Life: mixed results, significant ↓ in 2 Mixed results, no clear indication
1A Behavioral Therapy [Psychologist and No meta-analysis.
[19] out of 5 studies; Depression: mixed results, 2 for adding CBT to PT (LoC 1)
(CBT) to PT (n = 965) physiotherapist]
studies show no changes, while one study shows
exacerbation of depressive symptoms after
adding CBT.
54
Compared to waitlist or usual care: Significant Yes, while there is no difference
Group-based pain reduction at short-, intermediate, and with active treatments at short and
physiotherapist-led intermediate follow-up, behavioral
long-term follow-up.
behavioral Monodisciplinary Heterogeneity in treatments appear more effective at
Zhang, 2019 [20] 1A Compared to active treatment: No difference
psychological [Physiotherapist] methods. long-term follow-up.
between groups at short- or intermediate, but
interventions (n = 1927) There are indications that the
significant lower pain after behavioral therapy at
Meta-analysis addition of behavioral components
long-term follow-up. can reduce sick leave.
Walking is not more effective for
Same conclusion in reducing pain and disability
Walking interventions
Pain, disability, quality of life and fear-avoidance Not stated similar meta-analysis by compared to exercise or education,
Vanti, 2019 [21] 1A (n = 510)
improve equally by walking or exercise. [Physiotherapist] Sitthiporn-vorakul, 2018 but can be used as a low-budget
Meta-analysis
[22] and easy accessible alternative
(LoC 1)
Table 1. Cont.
Mono-/Multi-/
Sample Practice?
Compared to education/advice:
Functional disability ↓ at short, mid and long
Primary Care term; Pain ↓ at short, mid and long term; Mono- or multidisciplinary Use of bio-psychosocial
Heterogeneity in study
Quality of life: No differences
J. Clin. Med. 2019, 8, 1063
Interventions Using a [Physiotherapist, combined interventions in primary care is

Van Erp, 2018 [23] 1A and treatment designs.
Biopsychosocial Compared to physical activity therapy: with nurses, psychologist, or beneficial over education and
No meta-analysis.
Approach (n = 1426) Functional disability: No differences; Pain: mixed occupational therapist] advice (LoC 1)
results, 2 out of 4 studies report significant ↓ in
pain in biopsychosocial approach
Pooled results of aerobic and resistance
Aerobic and resistance training: Small significant improvement in pain Monodisciplinary Moderate quality evidence for the
exercise interventions
Wewege, 2018 [24] 1A and a trend towards significance for decreased [Physiotherapist or exercise / use of aerobic and resistance
(n = 322)
disability and improved mental health. No therapist] training (LoC 1)
Meta-analysis
differences were found for physical health (SF36).
In global group: Short-term ↓ in disability, but
Movement control not in pain compared to active control treatment. Very low to moderate quality of
Small sample sized and
Luomajoki, 2018 exercise therapy No long-term effects. Monodisciplinary evidence to use movement control
1A heterogeneity of
[25] (n = 781) In subgroup with movement control [Physiotherapist] exercises in CLBP AND movement
included studies.
55
Meta-analysis impairment: Short- and long-term ↓ in pain and control impairment (LoC 1)
disability.
Pain: Low quality of evidence for reduction at
short term, but not at intermediate or long-term
Monodisciplinary Because of low quality of evidence,
Back School (n = 4105) follow-up compared to no treatment.
Parreira, 2017 [26] 1A [Physiotherapist or medical Low quality of evidence back schools are not recommended
Meta-analysis Disability: Low quality of evidence that back
specialist] for CLBP (LoC 1)
schools are not effective at intermediate or
long-term follow-up compared to no treatment.
Table 1. Cont.
Mono-/Multi-/
Sample Practice?
Pain: Significant reduction using
self-management at immediate, short-term,
Mono- or multidisciplinary, Yes, there is moderate-quality
intermediate and long-term follow-up compared
Self-management and/or internet-based evidence that self-management has
to a control intervention.
J. Clin. Med. 2019, 8, 1063
Du, 2017 [27] 1A (n = 2188) [Physiotherapist, psychologist, / a moderate effect on pain intensity,
Disability: Significant reduction using
Meta-analysis exercise therapist, and/or and small to moderate effect on
self-management at immediate, short-term,
internet-based] disability (LoC 1)
intermediate and long-term follow-up compared
to a control intervention.
There is limited evidence that
graded activity significantly
reduces disability in the short and
Graded activity vs other forms of exercises: No long term compared to a control
difference for disability, quality of life or pain at intervention, but not when
any time-point. compared to an active control
Poor methodological
Graded activity vs waitlist or usual care: Graded intervention.
Graded Activity and quality of many
López-de- activity is more effective to reduce disability, but There is strong evidence that
Graded Exposure Not stated included studies.
Uralde-Villanueva, 1A not pain at short- and long-term follow-up. graded activity cannot change pain
(n = 1486) [Not stated] Possible publication
2016 [28] Graded activity vs graded exposure: Graded in the short, intermediate, and long
Meta-analysis bias could not be
exposure was more effective to reduce disability term compared to a control
56
assessed.
and catastrophizing in the short term. There is no intervention.
difference between both regarding the effect There are indicative findings that
on pain. graded exposure is better than
graded activity at decreasing
disability and catastrophizing in
the short term. (LoC 1)
Compared to other exercises: Small, but not
clinically important effect on pain and disability
at short term, but not at intermediate or long-term
follow-up. Motor control exercises are more
Motor control exercise Compared to manual therapy: No effect on effective than a minimal
Saragiotto, 2016 Not stated
1A (n = 2431) pain and disability. / intervention, but is not more
[29] [Not stated]
Meta-analysis effective than other forms of
Compared to minimal intervention: Clinical
exercise or manual therapy (LoC 1)
important effect on pain at short- and long-term.
Small, but not clinically important effect on
disability at short- intermediate and long-term.
Table 1. Cont.
Mono-/Multi-/
Sample Practice?
Both sensory discrimination and control Conflicting evidence,
Conflicting evidence, no clear
Sensory discrimination treatments (TENS, back school, sham treatment) Monodisciplinary low quality of included
Kälin, 2016 [30] 1A conclusion or recommendation
training (n = 255) led to a decrease in pain and an improvement in [Physiotherapist] studies.
possible (LoC 1)
function. No meta-analysis.
J. Clin. Med. 2019, 8, 1063
Pain: Pilates is more effective at short and

intermediate term compared to minimal Pilates is more effective than
Although the review
intervention, but not compared to other exercise minimal intervention (low- to
focused on (sub)acute
Pilates (n = 510) interventions. Monodisciplinary moderate quality of evidence), but
Yamato, 2015 [31] 1A and chronic LBP, but all
Meta-analysis Disability: Pilates is more effective at short and [Pilates instructor] there is no evidence for the
included studies dealt
intermediate term compared to minimal superiority of Pilates to other
about CLBP.
intervention, but not compared to other exercise forms of exercise (LoC 1)
interventions.
Compared to usual care: Multidisciplinary
Multidisciplinary
biopsychosocial rehabilitation is more effective to Yes,
Multidisciplinary [Physical, psychological,
reduce pain and disability, even at long-term. Clinical heterogeneity multidisciplinary biopsychosocial
biopsychosocial educational, and/or
Kamper, 2015 [32] 1A Compared to physical treatment: among included rehabilitation is more effective than
rehabilitation (n = 6858) work-related components
Multidisciplinary biopsychosocial rehabilitation is studies. usual care or physical treatment
Meta-analysis delivered by expert healthcare
more effective to reduce pain and disability, even (LoC 1)
providers]
57
at long-term.
General comparison: Exercise has a small but
significant benefit for the treatment of non-specific
CLBP and is more effective than conservative
Yes. Beneficial effect of
therapies (wait list or usual activities, general
Exercise interventions Heterogeneity in strength/resistance and
practitioner Not stated
Searle, 2015 [33] 1A (n = 4462) application of exercise coordination/stabilization exercise
care, electrotherapies and manipulative therapies). [Not stated]
Meta-analysis interventions. programs over other interventions
Sub-analysis: Strength/resistance,
(LoC 1)
coordination/stabilization, and combined exercise
is more effective than conservative therapies, but
not cardiorespiratory exercise.
Table 1. Cont.
Mono-/Multi-/
Sample Practice?
Perceptual proprioceptive training: More
effective for pain reduction than back school. Two
studies, very low quality of evidence.
Joint repositioning training: More effective for
J. Clin. Med. 2019, 8, 1063
short-term pain reduction than no intervention. Overall low quality of No consistent benefit in adding
McCaskey, 2014 Proprioceptive exercises Monodisciplinary
1A No difference with other exercises. Low quality of evidence. proprioceptive exercises for CLPB
[34] (n = 1380) [Physiotherapist]
evidence. No meta-analysis. rehabilitation (LoC 1)
Multimodal proprioceptive training: More
effective for short-term pain reduction than no
intervention. No difference with other exercises.
Low quality of evidence.
Sling exercises are not more effective for Based on the available evidence,
Sling exercise (n = 706) Not stated Low quality of included
Yue, 2014 [35] 1A improving pain or function compared to other sling exercises are not
Meta-analysis [Not stated] studies.
forms of exercise. recommended (LoC 1)
Pain and disability improved directly
post-treatment (moderate to large effect sizes) and Heterogeneity in yoga
Holtzman, 2013 Yoga (n = 851) remained at long-term follow-up (small to Monodisciplinary interventions. High Yes, possible adjunctive to PT
1A
[36] Meta-analysis medium effect sizes). Effects were compared to no [Yoga therapist] quality of included intervention (LoC 1)
58
treatment/waitlist, stretching, usual care, studies.
education and exercise.
Compared to waitlist: Psychological
interventions are superior to reduce pain intensity Psychological interventions are
Psychological
Hoffman, 2007 and health-related quality of life. Mono- or multidisciplinary more effective than no intervention,
1A interventions (n = 1747) /
[37] Compared to active control (e.g., treatment as [Not stated] but not compared to active
Meta-analysis
usual) intervention: Psychological interventions interventions (LoC 1)
are not superior
Level of Evidence (LoE): 1A: Systematic review of randomized controlled trials; 1B: Individual randomized controlled trials; 2A: Systematic review of cohort studies; 2B: Individual
cohort study or low quality randomized controlled trials; 3A: Systematic review of case-control studies; 3B: individual case-control study; 4: Case-series; 5: Expert opinion.
Level of Conclusion (LoC): LoC 1: Research of evidence level 1A or at least 2 independent conducted studies of evidence level 1B; LoC 2: 1 research of evidence level 1B or at least 2
independent conducted studies of evidence level 2B or 3B; LoC 3 1 research of evidence level 2B, 3B or 4; LoC 4: Opinion of experts or Inconclusive or inconsistent results between
various studies. Abbreviations: LoE = Level of Evidence; LoC = Level of Conclusion; PT= physiotherapy; CLBP = Chronic Low Back Pain.
J. Clin. Med. 2019, 8, 1063
2.2. Physically Inactive Interventions

Investigated inactive techniques for CLBP include therapeutic ultrasound, kinesiotape, pain
neuroscience education, transcutaneous electrical nerve stimulation, massage, osteopathic intervention,
and spinal manipulative therapy (including high-velocity low-amplitude spinal manipulations as well
as low-velocity low-amplitude mobilizations). Out of these therapies, only two are recommended, and
only when implemented as adjunctive therapy: pain neuroscience education and spinal manipulative
therapy. All other inactive interventions (i.e., therapeutic ultrasound, kinesiotape, transcutaneous
electrical nerve stimulation, massage and osteopathic interventions) are not recommended for CLBP
management based on available evidence.
Pain neuroscience education aims to decrease the threat value of pain by increasing the patient’s
knowledge about pain and by reconceptualizing pain [38]. As stand-alone intervention, this treatment
modality can reduce disability and kinesiophobia short term, but is not able to change pain [13].
However, when combined with other physiotherapeutic interventions, pain neuroscience education
can significantly reduce pain short term [13]. Therefore, pain neuroscience education can be considered
as a first step before applying an active intervention for people with CLBP. Given that many people
with CLBP display kinesiophobia (i.e., fear of movement and avoidance behavior, which is a barrier
for positive treatment outcome) [39], and active interventions are recommended (see below: ‘active
interventions’ and ‘international guidelines’) [40], pain neuroscience education can prime people for
further treatment by adapting beliefs and expectations. We would like to emphasize that—although
here discussed among physically inactive interventions—pain neuroscience education requires a
certain degree of activity of the patient. Pain neuroscience education should be delivered using
intense interaction between the patient and the therapist, and therefore requires mental and cognitive
activity of the patient [41,42]. Additionally, pain neuroscience education appears to enhance physical
activation and its effects on pain, given the evidence that combining pain neuroscience education with
a (therapeutic) exercise intervention is more effective than an exercise intervention alone (large effect
size for pain intensity) [13,43]. Manuals to implement pain neuroscience education are available in
books [44,45], and tools for clinical practice can be found online [46].
Similarly, spinal manipulative therapy can be used in clinical practice for CLBP management, but
only as part of a treatment package (i.e., adjunctive therapy) given the moderate quality evidence
from improvements in pain and function at short-term follow-up (1 month) but not at long term (6
or 12 months follow-up) [18,40,47,48]. Importantly, evidence reports several possible adverse events
related to spinal manipulative therapy, which should be taken into account by the clinician before
using these techniques. Reported adverse events include severe back pain, acute flare-up of back
pain, inability to sleep because of pain, muscle soreness and stiffness, exacerbation of symptoms,
and tiredness [18]. Interestingly, a randomized controlled trial examined if the effects on pain
differed between region-specific and non-region-specific spinal manipulations in people with CLBP
(n = 148) [49]. While both groups showed a reduction in pain intensity after the manipulation, they
did not find any differences between region-specific and non-region-specific techniques. This finding
appears to refute any local, biomechanical mechanisms behind the effectiveness of these techniques [49].
Changes in pain in response to manipulative techniques in people with CLBP could therefore be more
related to a cascade of neurophysiological responses from both the peripheral and central nervous
system as well as nonspecific effects such as expectations and psychosocial factors, rather than local
tissue changes [49].
As the effects of spinal manipulative techniques in CLBP might be explained by similar mechanisms
contributing to the positive effects of pain neuroscience education, some researchers suggest to combine
both recommended physically inactive adjunctive therapies discussed here [50,51]. Given their similar
recommendation (i.e., as adjuvant therapy to active treatment modalities), discussing their simultaneous
application in clinical practice becomes relevant. Because of the aim of pain neuroscience education to
shift the patient’s focus away from the tissues in the low back as the source of their pain, many could
conclude that pain neuroscience education should be used solely within a hands-off treatment approach.
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Yet, the meta-analysis of Wood et al. (2018) includes papers that combine pain neuroscience education
with other physiotherapeutic interventions such as exercise/activity and/or manual therapy [13].
Outcomes appeared to favor the combination of pain neuroscience education with movement, either
passive (manual therapy) and/or active. This suggests that combining pain neuroscience education
with “hands-on” approaches results in more favorable responses than pain neuroscience education
alone [51]. Yet, given the statement of The American Physical Therapy Association (APTA) that warns
us for the negative effects of applying physically inactive treatments (i.e., they can delay recovery and
lead to poor long-term outcomes by reinforcing a passive role, promoting inactivity and disability
behavior, and ‘medicalizing’ the patient), combining pain neuroscience education with active exercise
therapy might still be preferred over any physically inactive approach.
If a clinician were to combine pain neuroscience education with “hands-on” techniques, care
should be taken that all communication to the patient fits within the biopsychosocial framework of
PNE. Therefore, it should be avoided to present manual techniques within a biomedical pain model, in
which the therapist is deemed to “fix” a structure [52,53]. Instead, communication can focus on the
desensitizing effects of “hands-on” techniques and threatening words such as “pain” can be replaced
by more neutral terms like “symptoms” [52,54].
2.3. Physically Active Interventions

Given the listed active interventions in Table 1 and their recommendations, physically active
interventions appear to have more potential to alter symptoms in CLBP than physically inactive
interventions. Yet, the following four treatment modalities are not recommended due to lack of
qualitative evidence and/or conflicting evidence: back schools, sensory discrimination training,
proprioceptive exercises, and sling exercises [26,30,34,35]. Therefore, based on current evidence, these
types of therapy should not be considered for CLBP management.
The other active therapies for CLBP listed in Table 1 can be subdivided in physiotherapeutic
treatment modalities that include a psychological component (i.e., multimodal), and treatment
modalities that focus purely on physical exercises and movements. All included exercise modalities
(aerobic exercise, strength/resistance exercise, coordination/stabilization exercise, motor control, and
pilates) can effectively reduce pain and disability compared to minimal, passive/conservative, or no
intervention [24,29,31,33]. However, when compared to each other (or to other active treatments),
no differences can be found between different exercise modalities [24,29,31,33]. This is at odds with
evidence in healthy people, where—for example—resistance training can reduce pain sensitivity to a
greater extent than aerobic exercise [55].
Taken together, the information available regarding exercise interventions in CLBP and the wide
variety in duration, intensity and methods of training, we cannot recommend which groups or types
of exercise interventions are most effective [24,29,31,33]. From a motivational point of view, we
recommend taking the patient’s preferences and abilities into account when deciding upon exercise
modalities to use. Interestingly, when exercise therapy reduces pain and disability in people with
CLBP, the improvements are often unrelated to an improvement in physical function [56]. Therefore, it
is suggested that other exercise-induced changes like improved psychological status and cognitions
(e.g., reduced anxiety, catastrophizing, and fear) influence pain and disability more than changes in
physical function. This might explain the difficulties currently encountered to identify the optimal
exercise modality and dosage for CLBP management [24,57]. This statement is (partly) underscored
by the evidence on treatment modalities that combine exercises with a psychological component (i.e.,
biopsychosocial approach) [20,23,32].
Three systematic reviews (two of which included a meta-analysis) focused on the effectiveness
of a biopsychosocial treatment approach [20,23,32]. This approach involves a physical component
combined with a psychological component and/or a social/work targeted component [32]. Results of
this approach compared to other active treatments are promising. For example, while there was no
difference at short- and intermediate-term follow-up, behavioral psychological interventions were
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J. Clin. Med. 2019, 8, 1063
more effective to reduce pain at short-term and long-term follow-up than active treatments without a
psychological component [20,58,59]. Interestingly, the best results were found for multidisciplinary
biopsychosocial rehabilitation [32]. Importantly, the systematic review and meta-analysis investigating
this rehabilitation approach does not allow to differentiate whether the positive results emanate
from the multidisciplinary approach, the biopsychosocial focus, or both, as comparator studies
all involved a monodisciplinary biomedical approach (e.g., electrotherapy, aerobic, stretching and
strengthening exercises, traction, TENS, manual therapy, back school, surgery, etc.) [32]. Yet, both
compared to monodisciplinary usual care and to monodisciplinary physical treatment, multidisciplinary
biopsychosocial rehabilitation was found to be more effective to reduce pain and disability, even at
long-term follow-ups [60–67]. These results indicate that a multidisciplinary biopsychosocial approach
can provide CLBP patients with relevant tools to maintain positive treatment effects long term. This is
underscored by evidence that the effect on work equates to a person having roughly double the odds
of being at work after 12 months if they received a multidisciplinary rehabilitation program rather
than a physical treatment alone [32,68–71]. Interestingly, studies focusing on the costs-effectiveness
of interdisciplinary rehabilitation programs for chronic (pediatric) pain in general found significant
reductions in medical costs post-treatment compared to the pretreatment phase [72–74].
Yet, a multidisciplinary approach can be time-consuming, and resource intensive. As there is
currently no evidence available that directly compares a biopsychosocial approach in a monodisciplinary
versus a multidisciplinary setting, future researchers should focus on the question if it is the
multidisciplinary or rather biopsychosocial focus that explains these positive results. Interestingly, a
large randomized controlled trial recently conducted by our group has investigated the effectiveness
of a biopsychosocial approach (i.e., combining pain neuroscience education and cognition-targeted
exercise therapy) delivered monodisciplinary by a physiotherapist only [75]. This approach was able
to reduce pain, symptoms of central sensitization, and to improve psychophysiological measures of
central sensitization, disability, pain cognitions, mental health and physical functioning (medium to
large effect sizes) compared to an active control treatment. Using this example, we want to underscore
that even in a monodisciplinary setting a biopsychosocial approach can be effective and should be
targeted by clinicians. A treatment manual of this approach is published and can be accessed freely
online (https://bit.ly/2WcA1re) [76].
The added value of a combined, biopsychosocial approach (i.e., adding psychological components
to active physiotherapy treatments) is further underscored by a systematic review and meta-analysis
that focused on the effectiveness of stand-alone psychological interventions for CLBP [37]. This review
concluded that, compared to a waitlist, psychological interventions were superior to reduce pain
intensity and improve quality of life, but showed equal results when compared to an active (i.e.,
exercise) control intervention [37].
Additionally, we would like to highlight the possible advantage of incorporating graded exposure
techniques into the management of chronic low back pain. Graded exposure is a treatment modality
that identifies feared exercises or activities, and exposes the patient to these exercises or activities in
a hierarchical fashion, starting with an exercise or activity that elicits minimal amounts of fear and
progressing only when this fear reduces [28]. One systematic review and meta-analysis focusses both
on graded activity and graded exposure in nonspecific CLBP [28]. While graded activity can only
improve disability when compared to a waitlist or usual care control group and does not show superior
to other forms of exercises, there is some indicative research showing that graded exposure is more
effective than graded activity to improve disability and catastrophizing short term [28]. However,
currently there are no systematic reviews or meta-analyses available to allow firm conclusions on
the potential of graded exposure in chronic low back pain management. Therefore, we suggest that
clinicians can screen for the possible presence of feared movements and activities, and to tackle them
using graded exposure techniques upon occurrence [77,78].
Last, we would like to underline a recent meta-analysis on the effectiveness of walking
interventions [21]. When compared to education or other active exercises, walking improves pain,
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disability, quality of life and fear-avoidance to a similar extent. Therefore, walking interventions are
not recommended as sole use, but given the low-budget and easy, accessible characteristics of walking,
it can be a valuable home-based addition to other therapy modalities as it can increase physical activity,
overcome activity avoidance, and minimize barriers for other types of exercise [21,22]. Walking at a low
to moderate intensity imposes low risk of (musculoskeletal) injury and can improve aerobic capacity,
body mass index, systolic/diastolic blood pressure, triglyceride levels, and high-density lipoprotein
cholesterol levels in both healthy and sedentary individuals [22,79,80]. Therefore, clinicians should
consider implementing walking exercises for CLBP management, when combined with other types of
recommended, active treatment.
2.4. International Guidelines

A critical review of LBP guidelines (2017) [81] used the Appraisal of Guidelines Research and
Evaluation (AGREE) instrument to assess their quality and recommends four (out of 17 available)
guidelines for LBP management [40,82–84]. Two of these guidelines (NICE guidelines and Dutch
physiotherapy guidelines) focused on CLBP as a specific group apart from (sub)acute LBP [40,82] and
will be discussed here. For the NICE guidelines, we refer to the updated version that was published in
2016. Additionally, the recommendations of two more recently published guidelines that were not
yet included in the critical review will be discussed [85,86]. An overview of the recommendations
included in these (clinical) guidelines can be found in Table 2. We will not discuss all recommendations
in detail here but will rather highlight some striking features and parallels between guidelines.
Although several differences exist between the different guidelines, exercise is recommended in
all of them [40,82,85,86]. Interestingly, all of them also recognize that none of the exercise modalities
is superior to the others: health care providers can choose any type of exercise (general, aerobic,
strengthening, yoga, group-based or individual, etc.), but should specifically consider the patient’s
preferences, needs and capabilities while choosing the exercise modality. The NICE guidelines even take
it one step further and identify exercise as key treatment modality for LBP, given the recommendation
to only consider manual therapy and/or psychological therapies if it is a part of a treatment package
including exercise [40]. For multidisciplinary biopsychosocial rehabilitation—the intervention that
shows high potential based on available systematic reviews and meta-analysis (see Table 1)—the
NICE guidelines recommend considering this approach when significant psychosocial obstacles limit
recovery, or when previous treatments have not been effective.
Importantly, these guidelines all agree not to recommend transcutaneous electrical nerve
stimulation, interferential therapy (electrotherapy), or ultrasound for the treatment of CLBP. Other
not-to-use modalities in CLBP management as identified in at least one of these guidelines are:
traction, biofeedback, massage, laser therapy, taping, lumbar support, postural exercises, orthotics,
and percutaneous electrical nerve stimulation. Interestingly, all modalities that are not recommended
comprise physically inactive techniques, i.e., this implies lack of participation from the individual
receiving the therapy intervention. This is in line with the conclusions made based on the systematic
reviews (and meta-analysis) included in Table 1. The American Physical Therapy Association (APTA)
even warns us of the negative effects of applying physically inactive treatments for any type of patient:
these treatments can delay recovery and lead to poor long-term outcomes by reinforcing a passive role,
promoting inactivity and disability behavior, and ‘medicalizing’ the patient [87]. Given the ‘active’
focus of recommended treatment modalities, this advice should also be taken into consideration when
treating patients with CLBP. While physically inactive treatments (like manual therapy) appear to
have potentially positive effects, they should not be used as sole treatment but rather in a multimodal
approach focusing mainly on activating the patient [40].
62
Table 2. Overview of recommendations in (clinical) guidelines for chronic low back pain management.
Guideline Recommendation for CLBP
- Exercise therapy (not clear which exercises are best): Strong evidence that exercise
therapy is equally effective compared to passive physiotherapy techniques. Strong evidence
that exercise therapy is more effective than standard care by the general practitioner.
Recommended
J. Clin. Med. 2019, 8, 1063
- Behavioral treatment: may be useful. Strong evidence for a moderately positive effect on
pain compared to no treatment, waitlist or placebo. Effectiveness compared to other
treatments not clear.
Bekkering et al. Dutch
Physiotherapy Guidelines for
Low Back Pain (2003) [82] - Traction
- Biofeedback
- Massage
Not recommended - Transcutaneous electrical nerve stimulation
- Ultrasound
- Electrotherapy
- Laser therapy
63
- Education: Advice and information promoting self-management, evidence-based
information on expected course and effective self-care options, advice to stay active.
- Exercises: No recommendations for or against any specific type of exercise, consider
patient preferences.
Wong et al. Clinical guidelines Recommended - Manual therapy, including spinal manipulation
for the noninvasive
- Multimodal rehabilitation: including physical and psychological interventions (e.g.,
management of low back pain
cognitive/behavioral approached and exercise).
(2016) [86]
- Recommended by some guidelines: Massage, acupuncture, antidepressants.
- Muscle relaxants
- Gabapentin
Not recommended - Passive modalities, including transcutaneous electrical nerve stimulation, laser,
interferential therapy and ultrasound.
Table 2. Cont.
- Exercise: Moderate-quality evidence for small improvements in pain relief and function
when compared to no exercise or usual care. No evidence on which exercise regimen is best.
- Motor control exercise: Low-quality evidence for the effectiveness of motor control exercise
J. Clin. Med. 2019, 8, 1063
(small improvements in pain and function) compared to minimal intervention, general

exercise, and multimodal physical therapy. Low quality of evidence found no differences
between motor control exercises plus exercise or exercise alone.
- Tai Chi: Low-quality evidence showed that Tai Chi results in moderate pain reduction
compared to waitlist or no intervention.
Recommended - Yoga: Low-quality evidence showed that yoga results in a small pain reduction compared
to exercise.
- Psychological therapies: Low-quality evidence showed positive effects of progressive
relaxation therapy, mindfulness relaxation, electromyography biofeedback training, operant
therapy and cognitive behavioral therapy compared to waitlist. Low-quality evidence
Qaseem et al. Noninvasive shows no difference between psychological therapies and exercise or physical therapy, and
treatments for acute, subacute no difference between psychological therapies plus exercise and exercise alone.
and chronic low back pain
- Multidisciplinary rehabilitation: Moderate-quality evidence for effectiveness to improve
64
(2017) [85]
pain and disability compared to usual care, no treatment, or physical therapy.
- Pilates
- Acupuncture: Low-to-moderate-quality evidence shows effectiveness of acupuncture but
Not Clear compared to no treatment or sham treatment. No improvement found in function.
- Spinal manipulation
- Low-level laser therapy
- TENS
- Ultrasound
Not recommended - Lumbar support
- Taping
Table 2. Cont.
- Self-management: Provide advice and information tailored to the patient’s needs and
capacities, including information on the nature of the pain, and encouragement to continue
normal activities.
J. Clin. Med. 2019, 8, 1063
- Exercise: Consider group exercise programs, take into account the patient’s specific needs,
preferences and capabilities when choosing the type of exercise.
- Manual therapy (spinal manipulation, mobilization or soft tissue techniques): Can be
used, but only as part of a treatment package including exercise, with or without
Recommended psychological therapy.
- Cognitive behavioral therapy: As part of a treatment package, including exercise, with or
without manual therapy.
- Multidisciplinary biopsychosocial rehabilitation: Consider a combined physical and
psychological intervention incorporating cognitive behavioral techniques when significant
National Guideline Centre. psychosocial obstacles limit recovery, or when previous treatments have not been effective.
NICE Guideline Low back
- Return to work: Promote and facilitate.
pain and sciatica (2016) [40]
- Normal activities of daily living: Promote and facilitate.
65
- Opioids
- Postural exercise or education
- Orthotics, belt, corsets or rocker sole shoes
- Traction
Not recommended - Acupuncture
- Ultrasound
- Percutaneous electrical nerve stimulation
- Transcutaneous electrical nerve stimulation
- Interferential therapy
J. Clin. Med. 2019, 8, 1063

Over the past decades, scientific understanding of CLBP has increased substantially. This has
shifted treatment approaches away from pure biomedical treatments to multimodal approaches that
acknowledge the complex biopsychosocial nature of CLBP. The latter includes addressing lifestyle
factors, like physical activity and sedentary behavior, exercise, stress, sleep, and nutritional aspects
(Figure 1). In the general chronic pain population, the influence of lifestyle factors like (chronic)
stress, insomnia and sleep problems, depression, smoking, alcohol, obesity and nutrition are already
acknowledged [88–92]. Additionally, the overview of best evidence non-invasive rehabilitation for
CLBP in this paper highlights the importance of physical activity and exercise therapy for CLBP
management. Still, within CLBP management specifically, other lifestyle factors have received little
attention in scientific literature so far. Yet, a multimodal lifestyle-centered approach (Figure 1) could
lead to a long-term decrease of the psychological and socio-economic burden of chronic pain.
Figure 1. Promising direction for further research: a multimodal lifestyle-centered approach for people
with chronic low back pain (CLBP).
Incorporating stress management in CLBP treatment could help patients to cope with everyday
stressors, and leads to a clinically meaningful reduction in disability even at long-term (one year)
follow-up [93]. Stress management can help to increase acceptance of physical discomfort and difficult
emotions [93]. The advantage of a multimodal approach that addresses different lifestyle factors can
be underscored by the interconnection between stress and sleep in people with CLBP [94]. Numerous
studies report a strong association between anxiety levels and insomnia severity [95,96], and daily
life stress can negatively impact sleep [97]. As poor sleep acts as a precipitating and perpetuating
factor [98], and can represent a barrier for effective chronic pain management [99], its importance for
CLBP management is evident. Additionally, people with chronic pain will spontaneously engage in
more physical activity following a better night of sleep [100], again underscoring the importance of a
multimodal lifestyle-centered approach.
Similar to sleep, overweightness and obesity are risk factors for developing LBP, and are associated
with more severe and debilitating pain as pain intensity and disability show dose-responses to Body
Mass Index, waist circumference, percent fat, and fat mass [101–107]. Unfortunately, overweight and
obesity are an often overlooked lifestyle factor of importance in CLBP, while overweight/obese people
with CLBP are likely to have more complex needs requiring a focus on lifestyle factors [108]. A recent
study examining a nonsurgical weight loss program (i.e., physical exercise plus changes in dietary
behavior) found that people with CLBP (n = 46) not only lost body weight, but also experienced
less pain and disability [109]. Given the uncontrolled nature of this study, methodologically-sound
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J. Clin. Med. 2019, 8, 1063
randomized controlled trials examining the added value of such an approach are needed. Yet, if
therapists were to implement a weight reduction program for CLBP management, this program should
include changes in diet, behavior and physical activity [109], given the American College of Sports
Medicine Position Stand that a moderate dietary restriction combined with a physical activity program
(i.e., a deficit of 500 to 700 kcal on the energy balance) is effective and delivers long-term results [110].
Importantly, such multimodal lifestyle approach should primarily be implemented as a
patient-centered approach, tailoring the included treatment aspects to the preferences and attitudes
of the individual. This includes continuous (non-)verbal communication, education during all
aspects of treatments, patient-defined goals, patient-empowerment, and a confident therapist who
has sufficient social and interpersonal skills and shows specific knowledge [111]. To optimize the
success rate of this approach, principles of self-monitoring, goal setting and feedback can also be
integrated [112,113]. Given the need for behavioral changes in such a lifestyle approach, motivational
interviewing techniques can help the therapist to overcome difficulties experienced by the patient to
engage in this positive health behavior [114]. For example, consequences of an unhealthy lifestyle,
as well as barriers for change, can be discussed, together with examples of how a better lifestyle can
impact pain and quality of life, including a plan-of-action [115]. Motivational interviewing aims to
develop autonomous motivation in the patient by increasing perceived competence, self-regulation
and self-efficacy [115]. As higher self-efficacy is one of the key factors associated with better treatment
outcome in chronic pain, motivational interviewing techniques are useful to consider even beyond
CLBP management [116,117]. Clinicians and researchers should focus on this multimodal approach to
CLBP to aim for long-term improvements in pain, disability and quality of life, rather than a short-term
relief. As this approach could increase the empowerment of the patient and thus increase their personal
control over the symptoms, the need for constant follow-up and supervision of a physiotherapist—and
the related socio-economic costs—could be diminished.
4. Conclusions
Given the high prevalence of CLBP, and the overwhelming evidence available on its possible
management, this paper aimed to give a clear overview of best evidence practice. To conclude,
most physically inactive therapies should not be considered for CLBP management, except for pain
neuroscience education and spinal manipulative therapy if combined with exercise therapy, with
or without psychological therapy. Regarding active therapy, back schools, sensory discrimination
training, proprioceptive exercises, and sling exercises should not be considered for CLBP management
due to a lack of qualitative evidence and/or conflicting evidence. Exercise interventions, on the other
hand, are recommended, but while all exercise modalities appear effective compared to minimal,
passive/conservative or no intervention, there is no evidence that some specific types of exercises are
superior to others. Therefore, we recommend choosing exercise modalities according with the patient’s
preferences and abilities. When combining exercise interventions with a psychological component,
effects are better than an approach without psychological component and remain at long term.
Key messages for CLBP rehabilitation
- Do not consider the use of therapeutic ultrasound, kinesiotape, transcutaneous electrical nerve
stimulation, massage and osteopathic interventions.
- Pain neuroscience education and spinal manipulative therapy can have positive effects but should
not be used as stand-alone treatment. Consider these modalities only as part of a treatment
package including exercise, with or without psychological therapy.
- Do not consider back school, sensory discrimination training, proprioceptive exercises, and
sling exercises.
- Exercise therapy is highly recommended, but it is not clear which duration, intensity and methods
of training are best.
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J. Clin. Med. 2019, 8, 1063
- Consider a combined physical and psychological intervention incorporating cognitive behavioral

techniques to maintain positive effects at long-term.
Author Contributions: Conceptualization, A.M, K.I. and J.N.; Literature search and data extraction, A.M.; Writing,
Original Draft Preparation, A.M..; Writing, Review & Editing, all authors; Supervision, J.N.
Acknowledgments: Anneleen Malfliet, Kelly Ickmans, and Eva Huysmans funded by the Research Foundation
Flanders (FWO), Belgium. This work is partially funded by the Berekuyl Academy Chair, funded by the European
College for Lymphatic Therapy, The Netherlands, and awarded to Jo Nijs, Vrije Universiteit Brussel, Belgium.
Iris Coppieters and Thomas Bilterys are both funded by the Applied Biomedical Research Program (TBM) of the
Agency for Innovation by Science and Technology (IWT) and the Research Foundation Flanders (FWO), Belgium.
Conflicts of Interest: Jo Nijs has co-authored a Dutch book for clinicians on pain neuroscience education, but the
royalties for that book are collected by the Vrije Universiteit Brussel and not him personally. Besides that, the
authors have no conflict of interest to disclose.
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74
Journal of
Clinical Medicine
Review
Best Evidence Rehabilitation for Chronic Pain Part 4:
Neck Pain
Michele Sterling 1,2,3, *, Rutger M. J. de Zoete 1,2 , Iris Coppieters 4,5 and Scott F. Farrell 1,2,3
1 RECOVER Injury Research Centre, The University of Queensland, 4006 Brisbane, Australia
2 NHMRC Centre of Research Excellence in Road Traffic Injury Recovery, The University of Queensland,
4006 Brisbane, Australia
3 Menzies Health Institute Queensland, Griffith University, 4222 Gold Coast, Australia
Anatomy, Faculty of Physical Education & Physiotherapy, Vrije Universiteit Brussel, 1090 Brussels, Belgium
5 Department of Rehabilitation Sciences and Physiotherapy, Faculty of Medicine and Health Sciences,
Ghent University, 9000 Ghent, Belgium
* Correspondence: m.sterling@uq.edu.au
Received: 16 July 2019; Accepted: 8 August 2019; Published: 15 August 2019
Abstract: Neck pain, whether from a traumatic event such as a motor vehicle crash or of a
non-traumatic nature, is a leading cause of worldwide disability. This narrative review evaluated the
evidence from systematic reviews, recent randomised controlled trials, clinical practice guidelines, and
other relevant studies for the effects of rehabilitation approaches for chronic neck pain. Rehabilitation
was defined as the aim to restore a person to health or normal life through training and therapy and
as such, passive interventions applied in isolation were not considered. The results of this review
found that the strongest treatment effects to date are those associated with exercise. Strengthening
exercises of the neck and upper quadrant have a moderate effect on neck pain in the short-term.
The evidence was of moderate quality at best, indicating that future research will likely change these
conclusions. Lower quality evidence and smaller effects were found for other exercise approaches.
Other treatments, including education/advice and psychological treatment, showed only very small
to small effects, based on low to moderate quality evidence. The review also provided suggestions
for promising future directions for clinical practice and research.
Keywords: neck pain; rehabilitation; exercise; psychology review
1. Introduction
The health and economic burdens due to neck and back pain are substantial, being the leading
cause of years-lived-with-disability worldwide [1]. The societal burden of these conditions is driven
by the fact that many cases do not recover from acute episodes but go on to develop persistent or
recurrent pain [2,3]. Neck pain may arise as a consequence of traumatic injury, usually a motor
vehicle crash (whiplash associated disorder—WAD) or be of a non-traumatic onset such as occurs
in office workers (termed ‘non-traumatic neck pain’ in this review). Some argue that there is little
difference between the two neck pain conditions and have developed classification systems that do not
differentiate between them [4]. However, direct comparisons between WAD and non-traumatic neck
pain have found the former group report higher levels of pain and disability [5], greater psychological
distress [5], more marked hyperalgesia and hypoesthesia indicative of nociplastic pain [6,7], and have
worse outcomes at follow-up [8]. These findings suggest that different mechanisms may underlie WAD
and non-traumatic neck pain and subsequently different classification systems and treatments may be
necessary depending on the patient presentation.

J. Clin. Med. 2019, 8, 1219
The aim of this review is a state-of-the-art overview of the best evidence rehabilitation for patients
with neck pain. The best evidence rehabilitation is reviewed in a way that clinicians can integrate the
evidence into their daily clinical routine. In addition, the state-of-the-art overview also serves clinical
researchers to build upon the best evidence for designing future trials, implementation studies, and to
develop new innovative studies.
2. State-of-the-Art
For this best evidence review, rehabilitation was defined as aiming to restore a person with neck
pain to health or normal life through training and therapy (Oxford dictionary definition). It will
include a review of active non-interventional treatments such as exercise, psychology, and multimodal
approaches. Interventional procedures (e.g., radio-frequency neurotomy), pharmaceutical treatment,
and passive treatments—such as acupuncture or manual therapy alone and not used in conjunction
with more active treatments—will not be included. For this review, a non-systematic search of scientific
studies was performed in MEDLINE (PubMed), Scopus, CINAHL, and Pedro using the following
search terms: chronic neck pain, neck pain, whiplash associated disorders, rehabilitation, exercise.
To minimize selection bias and to ensure high quality evidence was selected, systematic reviews and
meta-analyses were preferred and sought where possible. Recent high quality randomised clinical
trials (RCTs) not already included in systematic reviews were included as well as information from
large population-based cohorts and international clinical guidelines. High quality trials were defined
as those receiving a Pedro score of 6/10 or greater and Pedro scores are provided for each trial included
in this review. Both WAD and non-traumatic neck pain were included with the aim of separating the
results for both neck pain groups where possible. This review did not include cervical radiculopathy.
A summary of the results are provided in Table 1.
76
Table 1. Best evidence summary—systematic reviews and RCTs if conducted after publication of a relevant systematic review.
Key References
Level of Quality of Rehabilitation
Intervention Target Population Effect Size Site of Care and/or Treatment
Evidence Evidence Professions
Manuals
Reassurance,
advice,
education
J. Clin. Med. 2019, 8, 1219
Video in ED Small effect compared to no treatment at

WAD See systematic
focussing on Level I [9] Moderate intermediate follow-up, RR 0.79 (0.59 to 1.06), ED All
(n = 348) review
activation NNT:23
WAD
WAD See systematic
information Level I [9] Low No effect compared to generic advice ED All
(n = 102) review
pamphlet
NTNP
Booklet or email Level 1 [10] Moderate No effect compared to massage or exercise Primary All
(n = 64) See systematic
Booklet/neck NTNP Primary and review
Level 1 [11] Very low to low No effect All
school (n = 411) secondary
Exercise
77
WAD and NTNP Moderate to large at short-term follow-up, SMD Primary and
Level I [12] Moderate
(n = 241) (pain) −0.71 (−1.33 to −0.10) secondary
Strengthening Exercise See systematic
(upper quarter) Office workers with professionals review
Moderate effect vs. no intervention, SMD pain
neck pain Level I [13] Moderate Workplace
= 0.59 (0.29 to 0.89)
(n = 605)
Endurance
WAD and NTNP Primary and See systematic
training (upper Level I [12] Moderate Small at short-term follow-up Physiotherapists
(n = 198) secondary review
quarter)
Small at intermediate-term follow-up
WAD and NTNP Small to moderate effect on pain in the short to Primary and
Level I [12] Moderate Physiotherapists
(n = 71) intermediate term (SMD pain −0.59 (95% CI: secondary
Muscle control −0.97 to −0.20)) See systematic
(stabilisation) review
NTNP Low to Small effect on disability (SMD disability −0.44 Primary and
Level 1 [14] Physiotherapists
(n = 174) moderate (95% CI: −0.81 to −0.08)) vs. other treatments secondary
Small effect on pain & disability compared to
Stretching (neck Workers Exercise Exercise protocol
Level II [15] Pedro (8/10) ergonomic advice (−1.4; 95% CI −2.2 to −0.7 for Work place
& shoulder) (n = 96) professionals available at [15]
pain; −4.8; 95% CI −9.3 to −0.4 for disability)
Table 1. Cont.
Key References
Level of Quality of Rehabilitation
Intervention Target Population Effect Size Site of Care and/or Treatment
Evidence Evidence Professions
Manuals
Small effect on pain MD: −1.6 (−3.6 to 0.3)
Eye-neck
WAD & NTNP compared to no exercise Primary and See systematic
co-ordination/ Level I [16] Very low Physiotherapists
(n = 103) Meta-analysis for other outcomes could not be Secondary review
J. Clin. Med. 2019, 8, 1219
proprioception
conducted
WAD and NTNP Primary and Exercise See systematic
Qigong Level I [12] Moderate Small at intermediate-term follow-up
(n = 191) secondary professionals review
Moderate effect on pain and disability vs.
Level I * (high
NTNP various other treatments including exercise, Primary and Exercise See systematic
Yoga heterogeneity) Moderate
(n = 686) SMD pain = −1.13 (−1.60 to −0.66), SMD secondary professionals review
[17]
disability −0.92 (−1.38 to 0.47)
WAD, NTNP, workers Primary and Exercise See systematic
General exercise Level I [13,18] No effect
(n = 386) secondary professionals review
Small effect on pain and disability when
Psychological
WAD and NTNP Very low to compared to no treatment, SMD pain = −0.58 Primary and Psychology See systematic
treatments alone Level I [19]
(n = 168) moderate (−1.01 to −0.16), SMD disability = −0.61 (−1.21 secondary professionals review
78
(CBT)
to −0.01)
Combined WAD Level I * (high Moderate No effect on pain and disability See systematic
Physiotherapists
psychological (n = 211) heterogeneity) quality Medium effect on fear of avoidance Primary review
and physical [20]
treatments Acute WAD Level II (RCT) NA Medium to large effect on pain related disability Treatment protocols
Physiotherapists
delivered by (n = 108) [21] Pedro (8/10) compared to exercise only available at [21]
physiotherapists
Exercise and WAD and NTNP Primary and
Level I [22] No effect compared to exercise alone
manual therapy (n = 345) secondary
Levels of Evidence were defined as per the Oxford Centre for Evidence Based Medicine [23]. Quality of Evidence as per reported in Systematic reviews or per Pedro scale for RCTs.
* Indicates systematic reviews with high heterogeneity indicating caution is required with interpretation of results. WAD: whiplash associated disorders; NTNP: non-traumatic neck pain;
ED: emergency department; SMD: standardised mean difference; MD: mean difference; NNT: number needed to treat.
J. Clin. Med. 2019, 8, 1219
3. Reassurance, Advice, and Education

It is acknowledged that the provision of reassurance, advice, and education are subtly different
paradigms, but as they are often difficult to study in isolation, they have been included together for the
purposes of this review.
Providing advice and reassurance to the patient with neck pain is the first step in the rehabilitation
process and is often the first-line treatment recommended by clinical practice guidelines [24,25].
Currently, there is no clear guidance on the recommended content of reassurance, beyond the message
of a favourable prognosis and full recovery [24]. In a recent qualitative study, the views of both patients
with WAD and non-traumatic neck pain were sought about the issues that concerned them most.
We found that both groups of patients wanted similar kinds of information that were consistent with
themes of worry about possible undetected structural damage; distress about difficulty undertaking
usual activities; concerns about the future and hardships such as treatment costs and insurance
claims [26]. These findings may provide some direction to the nature of reassurance required by
patients with neck pain.
Various information and educational approaches including information booklets, websites, and
videos have been investigated for their effectiveness in improving outcomes following whiplash
injury [9]. This Cochrane review identified three overall themes for patient education: advice on
increasing activity, advice focusing on pain and stress coping skills, and workplace ergonomics and
advice on self-care strategies. The review found that an educational video of advice in the hospital
Emergency Department that focussed on resuming activity was more beneficial in decreasing acute
WAD symptoms than no treatment at 24 weeks follow-up (RR 0.79, 95% CI: 0.59 to 1.06) but not at 6
and 52 weeks. The number of patients who must receive this educational video intervention for one
to benefit was 23. The results were based on one RCT only. No other educational intervention was
found to be effective, including a WAD information pamphlet provided in ED [9]. Later systematic
reviews have found that structured patient education alone did not yield large benefits in clinical
effectiveness compared with other conservative interventions for patients with WAD or non-traumatic
neck pain [10,11].
Recent RCTs not included in the above-mentioned reviews have found similar results.
An educational treatment of pain management focusing on understanding/acceptance of pain, goal
setting, and participation in social- and work-related contexts was less effective in improving a physical
quality of life measure when compared to a multimodal treatment (the same education in addition to
exercise) for a mixed traumatic/non-traumatic neck pain sample [27] (Pedro 6/10). A preliminary RCT
in a small sample of women with mixed chronic neck pain also found that pain education was less
effective when delivered alone than when delivered in conjunction with exercise [28] (Pedro 7/10).
Education directed toward increasing a patient’s knowledge of pain neuroscience has gained
traction in recent years, mostly in the field of low back pain. Systematic reviews have found that this
approach has a small to moderate effect on pain and disability in the short-term immediately following
the intervention for patients with low back pain [29]. There is also moderate level evidence that the
use of pain neuroscience education alongside other physiotherapy interventions probably improves
disability and pain in the short term in chronic low back pain [30]. Pain neuroscience has been less
investigated in neck pain, with one preliminary RCT showing potential benefit when combined with
exercise for adolescents with non-traumatic neck pain [31] (Pedro 7/10).
Clinical message: Tested educational/advice treatments alone show only small effects for patients
with neck pain (WAD and non-traumatic neck pain). Better effects may be seen when educational
approaches are used in conjunction with exercise. The optimal content to be included in educational
approaches is not known.
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J. Clin. Med. 2019, 8, 1219
4. Exercise
Various types of exercise have been evaluated for their effectiveness in neck pain, including general
exercise and activity, neck specific strengthening or control exercises, and sensorimotor exercises.
Systematic reviews generally include all exercise types together. A recent comprehensive Cochrane
systematic review found no high quality evidence, indicating that there is still uncertainty about the
effectiveness of exercise for neck pain [12]. In an attempt to gain clarity around the effectiveness of
exercise alone, this review included only trials with single interventions that compared exercise with a
control or comparative group. Additionally, the authors used an exercise classification system based
on a clinical rationale for selecting studies with similar interventions to assist with interpretation and
inclusion within the meta-analyses [12].
Moderate quality evidence supported the use of upper quarter (neck, scapula, and upper limb)
strength training to improve pain immediately post treatment with a moderate to large effect (pooled
SMD (pain) −0.71 (95% CI: −1.33 to −0.10)) at short-term follow-up. There was also moderate
quality evidence to support: (i) upper-quarter endurance training for a small beneficial effect on
pain immediately post treatment and short-term follow-up; (ii) neck and shoulder girdle muscle
control (stabilisation) exercises to improve pain and function at intermediate term follow-up (MD
pain (100 point scale) −14.90 (95% CI: −22.40 to −7.39)); and (iii) Qigong (mindfulness and slow
movement exercise) to minimally improve function but not global patient perceived effect in the short
term. Low quality evidence suggested that breathing exercises; general fitness training; stretching
alone; and vestibular rehabilitation type exercises may not change pain or function at immediate post
treatment to short-term follow-up. Very low quality evidence suggested that neuromuscular eye–neck
co-ordination/proprioceptive exercises may improve pain and function at short-term follow-up,
supporting findings of a previous systematic review [16].
From this review, it should be noted that the best available evidence is at a moderate quality level,
meaning that further research is likely to have an important impact on the effect estimate. The review
also did not differentiate between WAD and non-traumatic neck pain, but there may well be different
responses to exercise (and other treatments) between the two neck pain groups as a consequence
of their different clinical presentation and features outlined earlier in this review. A later review
found similar results, concluding that supervised qigong, yoga, and combined programs including
strengthening, range of motion, and flexibility are effective for the management of persistent neck pain,
with no one program superior to another [32]. These authors also noted that effect sizes are small
indicating a small clinical benefit of exercise for chronic neck pain [32].
Other systematic reviews have investigated the evidence for one specific exercise type. Exercises
to improve control of the cranio-cervical flexion movement were found to have small to moderate
effect on pain in the short to intermediate term (SMD pain −0.59 (95% CI: −0.97 to −0.20)) and a
small effect on disability (SMD disability −0.44 (95% CI: −0.81 to −0.08)) when compared to other
treatments (other exercise, manual therapy) in people with non-traumatic neck pain [14]. However, the
meta-analysis revealed high heterogeneity indicating that results should be interpreted with caution.
Another systematic review without meta-analysis found that motor control exercises may not be any
more effective than a standard strengthening exercise program [33]. Yoga was found to have moderate
positive effects on pain (SMD −1.13 (95% CI:−1.60 to −0.66)) and disability (SMD = −0.92 (95% CI:
−1.38 to −0.47)) over other treatments (mostly other exercise) for people with chronic non-traumatic
neck pain [17] but the results had high heterogeneity, indicating caution is required with interpretation.
Two systematic reviews have evaluated the effect of general exercise and activity for neck pain
with both reviews acknowledging the limited number of trials available for inclusion. One review
found that there were no clinically meaningful differences between comprehensive exercise programs,
which included general exercise, and minimal intervention controls in the medium and long term [18].
A second review including studies of both non-traumatic neck pain and WAD found small effects on
pain that were probably not clinically significant [34].
80
J. Clin. Med. 2019, 8, 1219
Clinicians may want to understand if one form of exercise is more effective than another. While all
systematic reviews note small effects for most exercise types, it has been commonly assumed that there
is no difference between them. However, few direct head-to-head comparisons of different exercise
types have been undertaken and therefore firm conclusions cannot be drawn. Some data suggest
differential effects of exercise type on pain sensitivity. For example, isometric exercise may exert greater
hypoalgesic effects than aerobic exercise, at least in the short term [35], so it is possible that further
research may show that exercise type has different influences on pain.
Clinical message: Exercise seems to have beneficial effects on neck pain (WAD and non-traumatic
neck pain), although high quality evidence is lacking. There is moderate evidence indicating that
strengthening exercises of the upper quarter may have a moderate effect on pain, but further research
may change this result. At present, there is no data available to show that one form of exercise
is more effective than another. There is also no data to indicate the optimal dose or intensity.
Until further evidence becomes available, clinicians may want to take patient preference and their
clinical expertise with exercise prescription into account when providing an exercise intervention.
They should also consider the potential overall health benefits of exercise (particularly aerobic and
strengthening exercises).
5. Work Place Neck Pain

Office workers have the highest annual prevalence of neck pain (up to 63% depending on neck pain
definition) of all occupations [36]. Neck pain is a recurrent condition with 60–80% of workers reporting
a recurrence one year after the initial episode [37]. Ergonomic interventions such as adjustments to
the physical work space and equipment are commonly employed, with the aim of reducing physical
strain to the musculoskeletal system, thus reducing risk of injury. A recent Cochrane review found
inconsistent evidence that the use of an arm support or an alternative mouse may reduce the incidence
of neck and should disorders (risk ratio (RR) 0.52 (95% CI: 0.27 to 0.99)). For other physical ergonomic
interventions, they found no evidence of an effect and for organisational interventions, such as increased
work breaks, very low-quality evidence was found for an effect on the incidence of upper limb pain [38].
Another recent systematic review found low quality evidence that ergonomic programs do not reduce
the risk of a new episode of neck pain (OR 1.00 (95% CI: 0.74 to 1.35)) but moderate quality evidence
that an exercise program substantially reduces the risk of a new episode of neck pain (OR 0.32 (95% CI:
0.12 to 0.86)) [39]. The latter finding was based on two RCTs, one included aerobic, strengthening, and
stretching exercises and the other strengthening and stretching exercises [39].
For workers with neck and/or upper limb pain, another Cochrane review found very low quality
evidence that exercise interventions were no more effective than no treatment on pain disability and
sick leave [40]. This review also found that ergonomic interventions did not decrease pain in the
short term but did decrease pain in the long term (low quality evidence) [40]. An earlier review
found moderate quality evidence that a multiple-component intervention (including mental health
education, physical health education, relaxation and breaks, activity modifications, and physical
environmental modifications) reduced sickness absence in the intermediate-term (OR 0.56 (95% CI: 0.33
to 0.95)) which was not sustained over time but no intervention had an effect on pain [41]. However, a
more recent review and meta-analysis concluded that workplace-based strengthening exercises were
effective in reducing neck pain in office workers with a larger effect if the exercises were targeted to the
neck/shoulder with moderate quality evidence (SMD pain = 0.59 (95% CI 0.29 to 0.89)) [13]. There was
a dose–response relationship with greater participation in the exercise being associated with a larger
effect [13]. These conclusions were supported by another review that concluded that there is level
II evidence recommending that clinicians include strengthening exercise to improve neck pain and
quality of life [42]. Recommendations arising from all reviews were that further large high quality
clinical trials are needed.
Since the publication of these reviews, several RCTs have investigated various interventions for
workplace related neck pain. Neck and shoulder stretching exercise and ergonomic advice improved
81
J. Clin. Med. 2019, 8, 1219
neck pain and disability to a greater extent than ergonomic advice alone, with small effects (−1.4;
95% CI: −2.2 to −0.7 for visual analogue scale; −4.8; 95% CI: −9.3 to −0.4 for Northwick Park Neck
Pain Questionnaire) in workers with at least moderate neck pain (Pedro 8/10) [15]. However, Caputo
and colleagues found no difference between a twice-weekly 7-week group-based neck and shoulder
resistance exercise programme compared to group-based stretching and postural exercise of the same
duration [43] (Pedro 7/10).
Clinical message: Work-place strengthening programs may be effective for office workers with
non-traumatic neck pain and for preventing neck pain in asymptomatic workers. Evidence for the
effectiveness of ergonomic interventions is inconsistent.
6. Psychological Treatments
Similar to all chronic pain conditions, neck pain is associated with psychological factors such as
cognitive distress, anxiety, depressed mood, fear of pain and/or movement [44,45] and in the case of
WAD, posttraumatic stress symptoms [45]. Psychological factors likely play a role in the transition from
acute to chronic pain [46] and contribute to the extent and severity of pain and disability reported [46].
Treatments directed at psychological factors can decrease pain and disability [47].
Cognitive behavioural therapy (CBT) is one of the most common psychological treatments used
in the treatment of chronic pain conditions. CBT works by means of modifying maladaptive and
dysfunctional thoughts (e.g., catastrophising, kinesiophobia) and improving mood (e.g., anxiety and
depression), leading to gradual changes in cognition and illness behaviour. With respect to neck pain,
a recent Cochrane review found the quality of the evidence to be very low to moderate with only six
high quality RCTs being available for inclusion [19]. CBT was found to be more effective for short-term
pain (SMD pain −0.58 (95% CI: −1.01 to −0.16)) and disability (SMD disability −0.61 (95% CI: −1.21 to
−0.01)) reduction only when compared to no treatment. There was moderate quality evidence that CBT
was better than other interventions for improving kinesiophobia at intermediate-term follow-up (SMD
−0.39 (95% CI: −0.69 to −0.08)). For subacute neck pain, CBT was significantly better than other types
of treatment at reducing pain in the short-term (SMD pain −0.24 (95% CI: −0.48 to 0.00)), but there were
no effects on disability and kinesiophobia. Looking at psychological treatments more broadly, Shearer
and colleagues found no evidence for or against the use of psychological interventions (including
relaxation training and CBT) in patients with recent onset neck pain or WAD [48]. For chronic neck
pain, they found evidence that a progressive goal attainment program may be helpful.
The results of both systematic reviews illustrate the dearth of clinical trials investigating
psychological treatments for neck pain with only 10 RCTs eligible for inclusion. This is in comparison
to say low back pain, where systematic reviews have included up to 30 RCTs [49,50].
Clinical message: There is little evidence available to determine if psychological treatments alone
are effective for neck pain (WAD and non-traumatic neck pain).
7. Combined Treatments—Physical and Psychological Treatments

Many clinical trials have investigated interventions of mixed treatments and or disciplines.
The most recognised of these approaches is multidisciplinary rehabilitation. No systematic reviews
for multidisciplinary rehabilitation of chronic neck pain were located. A review of this approach for
chronic low back pain found modest positive effects on pain and disability compared to usual care or
physical rehabilitation [51].
A more common approach studied in patients with neck pain is to add a psychological treatment
to a physiotherapy program with both components delivered by physiotherapists. A recent systematic
review and meta-analysis of this combined approach found that, for neck pain and WAD, there
was no effect on pain or disability but statistically and probably clinically relevant effects on fear of
movement beliefs (SMD −0.5 (95% CI: −0.95 to −0.05)) and pain catastrophizing (SMD −0.31 (95%
CI: −0.54 to −0.08)) [20]. However, the meta-analysis revealed high heterogeneity, potentially as the
psychological interventions and usual physiotherapy/usual care were not uniform across the included
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J. Clin. Med. 2019, 8, 1219
RCTs. The definition of psychological intervention in this review was kept broad. Studies with larger
effects were more closely examined, revealing that these RCTs tended to use individually tailored
interventions. In addition, these interventions addressed patients’ maladaptive cognition through
the use of various cognitive techniques (e.g., identifying and challenging negative thoughts) while
aiming to modify patients’ maladaptive behaviours and increasing level of activities using a range of
behavioural strategies (e.g., breathing and relaxation techniques, goal setting, and graded activities).
Furthermore, some of these studies also encouraged patients to participate in the decision making
regarding goal settings and treatment. One of these studies included patients with WAD [52], with the
other being of patients with low back pain [53].
Since this review, one additional RCT investigating effects of combined
psychological/physiotherapy interventions has been published, all with slightly different approaches.
A recent RCT (StressModex) showed that a physiotherapist delivered exercise program and a
psychological treatment targeting initial stress related symptoms in patients with acute WAD and at
high risk of poor recovery, was more effective than exercise alone on pain related disability (primary
outcome) (Neck Disability Index at 6 weeks: −10.0 (−15.5 to −4.8); at 6 months: −7.8 (−13.8 to −1.8) and
at 12 months: −10.1 (−16.3 to −4.0)) and stress, depression and self-efficacy (secondary outcomes) [21].
The effect size on the primary outcome was moderate to large. The psychological component of the
combined intervention was consistent with that outlined in the above systematic review [20]—it
was a targeted intervention using cognitive strategies and behavioural strategies. Whilst there has
been no direct head to head comparison, the results of StressModex are superior to what has been
found for both ‘psychologically informed’ physiotherapy (MINT trial) [54] and early multidisciplinary
care [55] for acute WAD. In both these trials, there was no stratification of patients based on risk to
recovery and treating all patients as a homogenous group may dilute any treatment effect. The former
trial used less targeted strategies for dealing with psychological factors where the physiotherapists
questioned patients to identify treatment targets, such as beliefs about pain and coping strategies.
It is possible that the approach used in the MINT trial was too broad and although attempted to
address psychosocial factors, lacked the specificity to be effective. StressModex specifically targeted
one psychological risk factor and trained physiotherapists in its management as opposed to a more
broad approach and this may be a reason for the stronger effects seen. In the latter multidisciplinary
trial, patients were less compliant with psychology treatment compared to physiotherapy. Patients in
the acute stage of a physical injury may not see the relevance of seeing a psychologist for what they
perceive is a physical injury. This may be further justification for an enhanced role of physiotherapists
in the management of acute WAD (and other musculoskeletal injuries), with that role including the
management of psychological aspects of the condition in addition to physical ones.
With respect to non-traumatic neck pain, few trials have tested a combined
physiotherapy/psychological intervention. One RCT of fair quality (Pedro 5/10) found no added benefit
of a cognitive behavioural intervention to exercise on disability but clinically meaningful reductions in
pain [56].
Taken together, the results of these studies suggest that psychological treatments delivered by
physiotherapists may need to be individually targeted (personalized rehabilitation) as opposed to a
broad psychologically-informed approach. Further research is required to determine the important
and effective components of a physiotherapist-delivered psychological intervention.
Clinical message: Combined psychological and physiotherapy interventions delivered by
physiotherapists may be more effective than physiotherapy alone for WAD but these results need
further replication. The psychological component may be more effective if it specifically targets
individual psychological factors.
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8. Combined Treatments—Exercise and Passive Treatments

Manual therapy is a common treatment provided to patients with neck pain. It was not an aim
of this review to synthesise evidence for passive treatments used in isolation. However, as manual
therapy is often combined with exercise in clinical practice, it is worthwhile to consider if its addition
has any greater effects than exercise alone. A systematic review of RCTs including both WAD and
non-traumatic neck pain concluded that combined manual therapy and exercise was no more effective
than exercise alone in reducing neck pain intensity, neck disability, or improving quality of life [22].
In contrast, Hildago et al. [57] found moderate evidence supporting combined manual therapy and
exercise for acute to sub-acute neck pain and moderate to strong evidence for chronic neck pain. In
their systematic review, Sutton and colleagues [58] found that multimodal care—including education,
exercise, and manual therapy—can benefit patients with WAD and non-traumatic neck pain. They
also concluded that there is no additional benefit to providing frequent sessions of multimodal care to
patients with neck pain over an extended time period [58].
Clinical message: Adding manual therapy to exercise may be more beneficial than exercise alone,
but the evidence is conflicting.
9. Lifestyle Interventions
In recent times, attention has been paid to the potential role of lifestyle factors in the development
of chronic musculoskeletal pain. Epidemiological studies have found that higher levels of physical
activity are associated with less neck and shoulder pain [59] and physical inactivity and high Body Mass
Index are associated with an increased risk of chronic pain in the low back and neck/shoulders in the
general adult population [60]. Sleep problems have also been shown to be associated with an increased
risk of chronic pain in the low back and neck/shoulders [61]. These data suggest that interventions
directed at improving lifestyle factors may be effective for musculoskeletal pain, including neck
pain, but few trials have been conducted in this area. Williams and colleagues found that a 6-month
telephone-based healthy lifestyle coaching service intervention provided no benefit (primary outcome
was pain) over usual care for obese patients with low back pain [62] (Pedro 8/10). The intervention was
not successful in changing the targeted lifestyle factors such as weight, physical activity, diet, and sleep
and this may explain the lack of effect on pain [62]. No recent trials of lifestyle interventions for neck
pain were found but this could be an area of future research.
Clinical message: The effect of lifestyle interventions on chronic neck pain is unknown as no
studies have yet been conducted.
10. Patient Stratification and Sub-Grouping

The mostly small effects seen in clinical trials for musculoskeletal pain conditions have led to
suggestions that the small effects are due to the heterogeneity of the conditions and their subsequent
differential response. In response, there has been much debate about the merits or otherwise of
sub-grouping patients which may in turn lead to the identification of the most effective treatment for
each sub-group [63]. Some RCTs, using patient sub-grouping, have been conducted in low back pain
with limited effects seen [64]. With respect to neck pain, few studies looking at the benefits and effects
of patient sub-grouping have been conducted and all have been in WAD. In a preliminary RCT, a neck
and shoulder girdle specific exercise program was found to be more effective in patients with chronic
WAD and signs of central sensitisation (widespread mechanical and cold hyperalgesia) when compared
to those without these features [65] (Pedro 7/10). However, in this trial, the sub-group analyses were
not pre-defined and prior sample size calculations did not consider sub-group analyses, indicating that
the results should be interpreted with a high degree of caution. In a later trial with a priori sample size
calculations that included investigation of the moderating effects of several variables on the outcomes,
the results were not replicated [66]. No evidence was found that measures of central sensitisation or
psychological variables of posttraumatic stress symptoms moderated the effect of a 12-week exercise
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intervention in patients with chronic WAD [66]. Similarly, in patients with acute WAD (<4 weeks post
injury) providing different treatments based on the individual patient’s sensory and psychological
presentation provided no better effect than usual care [55]. In this RCT, if patients presented with
widespread hyperalgesia and significant psychological distress, they received physiotherapy exercise,
medication, and psychological treatment, whereas those without these features received physiotherapy
exercise alone. This pragmatic approach using patient sub-grouping was compared to usual care [55].
In summary, sub-grouping patients with WAD based on sensory and psychological measures has not
yet been successful.
Another approach has been to stratify patients, usually those with an acute condition, based
on their risk of recovery or non-recovery. Again, most research in this area has been in WAD. A
clinical prediction rule to identify both chronic moderate/severe disability and full recovery at 12
months post-injury was recently developed [67,68]. The results indicated that an initial Neck Disability
Index score of ≥40%, age ≥35 years, and a score of ≥6 on a hyperarousal symptom scale (symptoms
of trouble falling asleep, irritability, difficulty concentrating, being overly alert, and easily startled)
could accurately predict patients with moderate/severe disability at 12 months. It is also important to
predict patients who will recover well as these patients will likely require less intensive intervention.
Initial Neck Disability Index scores of ≤32% and age ≤35 years predicted full recovery at 12 months
post-injury. Further evaluation of the clinical prediction rule has shown that it performs comparably to
the more generic and commonly used Orebro Musculoskeletal Pain Questionnaire (short form) [69]
and may have better specificity (unpublished data).
The aim of a prognostic clinical prediction rule is to target treatment toward the identified risk
groups. For the whiplash clinical prediction rule, it is proposed that patients identified at low-risk of
poor recovery require minimal treatment consisting of advice, reassurance and simple exercises [70].
In contrast, it is suggested that patients identified at high risk of poor recovery will require further
assessment of potentially contributory factors including psychological distress, nociceptive processing,
and neck movement and strength [70]. Whether or not this risk stratified targeted approach results in
better patient outcomes is currently being evaluated with no data yet available.
Clinical message: Risk-stratification may be useful for patients with WAD but further research is
required before treatment based on stratification can be recommended.

Despite the existence of numerous clinical practice guidelines for non-traumatic neck pain and
WAD, most recommendations are based on low to moderate quality evidence or on consensus.
Clinicians need to be aware of this situation and while broadly following the clinical guideline
recommendations, be astute to the individual patient presentation, and adapt their treatments as
required. Nonetheless, it is clear that traditional rehabilitation approaches are not very effective and
that a step-change is needed to improve this situation. It is difficult to nominate promising directions
for clinical practice, as many areas require further research, so the following two sections overlap to
some extent. However, some findings if widely adopted in the clinical arena have the potential for an
immediate effect to improve health outcomes. Some of these are outlined.
Risk screening or stratification of patients early in development of their neck pain condition
followed by provision of a clinical pathway of care based on the patient’s risk of developing
chronic/persistent pain. There are several tools available to achieve this—WhipPredict for patients
with WAD, the short-form Orebro Musculoskeletal screen for WAD and non-traumatic neck pain, and
StartMSK for non-traumatic neck pain (see Table 2 for availability). Research suggests that rehabilitation
health care providers are not aware of prognostic indicators and do not use clinical risk screening tools
for patients with neck pain [71,72]. The majority of patients will fall into the ‘low risk’ category; in
other words, they should recover well with minimal treatment comprising a few sessions of advice,
reassurance, and exercise. Those deemed at ‘high risk’ require further evaluation including assessment
of psychological factors, nociplastic pain, and more complex movement problems that then could be
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J. Clin. Med. 2019, 8, 1219
specifically addressed. Whilst this stratified care model and subsequent care pathway is yet to be fully
evaluated for neck pain, there has been substantial research of a similar approach for low back pain.
Some trials in low back pain show good effect [73] but others have been more equivocal [74]. In this
latter trial conducted in the USA, the intervention resulted in use of the STarT Back risk screening tool,
but it did not change health care provider treatment decisions. Some reasons for this proposed by the
researchers were unacceptability to clinicians, inadequate leadership and system support, ineffective
implementation, and inadequate potency [74]. Neck pain researchers should take note of these issues
and they could be addressed in risk-stratified neck pain trials.
Table 2. Promising directions for clinical practice.
Treatment Approach Resources
• WhipPredict (Whiplash Clinical Prediction Tool) [67,68].

Electronic version available at
https://recover.centre.uq.edu.au/research/clinician-resources
• Hard copy available on author request
Risk screening/stratification of patients • Orebro Musculoskeletal Screening Tool Short-Form [69]
to determine risk of poor or delayed Available at https:
recovery //www.cesphn.org.au/documents/filtered-document-list/204-
oerebro-musculoskeletal-pain-screening-questionnaire/file
• StartMSK [75]. Available at
https://www.keele.ac.uk/startmsk/moreaboutthetool/
Clinical pathways of care based on risk • Under evaluation. Protocol available at [70]
stratification
• There are various protocols available but few that are specific to
Development of skills of rehabilitation neck pain
professionals to integrate some • The integration of a psychological treatment targeting stress
psychological treatments into standard related symptoms in people with acute WAD is available at the
physical rehabilitation following reference [21]
Provide advice and reassurance to • Preliminary findings of the needs of patients with WAD and
patients that is more targeted to their neck pain [26,76,77]
needs
The development of more horizontal across discipline (versus vertical siloed uni-discipline)
skills for rehabilitation professionals. It is clear that, like all musculoskeletal conditions, neck pain is
heterogeneous and the management of particularly the ‘high risk’ patient group requires skills that cut
across various disciplines. An example of cross discipline skills is the utilisation of physiotherapists
to deliver psychological type treatments. With respect to the targeting of psychosocial risk factors
in high risk patients, it has been previously argued in this review that individual specificity will be
required, with preliminary evidence showing a broader approach may not be as effective. If further
research supports this tenet, then rehabilitation professionals will need to upskill in the identification
and management of psychosocial risk factors. At least anecdotally, there seems to be some resistance
to this but the evidence is strong that psychosocial factors pay a role in musculoskeletal outcomes
and rehabilitation professionals including physiotherapists are well positioned to deliver care that
may be considered outside their traditional realm. One cautionary note. It is not advocated that
rehabilitation professionals deliver care to patients with a psychopathology such as severe depression
or posttraumatic stress disorders and these patients will need referral to a mental health professional.
Rehabilitation professionals will require skills in assessment of patient mental health so that appropriate
referral can be initiated. The upskilling of the rehabilitation workforce should commence from early
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J. Clin. Med. 2019, 8, 1219
undergraduate training and this may be already happening in some locations but is lagging behind in
others [78].
Provide advice and reassurance that is consistent with identified patient needs. Qualitative
research has begun to identify the needs of people with neck pain with respect to the information they
are seeking and these findings should lay the foundation for future trials. Some of the factors emerging
when talking to people with neck pain may not be traditionally included in advice and reassurance
delivered by rehabilitation health care providers. An example is concerns around treatment costs and
insurance claims reported by patients with WAD [26]. Psychological distress associated with claims
processes have been shown to interfere with recovery and quality of life [79]. Providing information
to patients regarding these processes may assist recovery. Another example would be information
about likely prognosis nominated as important by patients [76], but which health care providers
may not usually provide or be uncomfortable with how to deliver this information to patients. We
have consistently found that physiotherapists are not well aware of the consistent predictors of poor
recovery after whiplash injury [71,80], so may not routinely assess for such factors with the view of
gauging prognosis. There are clinical prediction rules available to identify patients both at risk of
poor recovery and those that will recover well [67–69] but to date the clinical uptake of these has been
slow. This may require more effective knowledge transfer and potentially a cultural change within the
physiotherapy profession.

Exercise is the staple approach for most rehabilitation professionals, but further evidence is
required to guide this key area of management. The role of exercise in managing neck pain should be
clarified including the comparisons of different exercise modalities (strengthening, muscle control,
aerobic, and so forth) and dosages. The rationale underpinning the use of exercise is to specifically
target underlying physical impairments, which will then impact on pain and disability [81]. However,
this assumption has been challenged. In a systematic review for low back pain, little correlation
between improvements in clinical outcomes such as pain and disability and improvements in physical
function with exercise were found [82]. Similar results were found in a review of neck pain [83] and in
a RCT of hip pain [84]. The results of both reviews suggest that improvements in self-reported clinical
measures with exercise may be more associated with other factors such as psychological and/or central
nervous system responses than by the rectification of specific physical impairments. Certainly, it is
clear that exercise exerts central inhibitory effects termed exercise induced hypoalgesia (EIH) [85] and
that EIH is impaired in some people with chronic pain including neck pain [35,86]. Further research is
required to understand central nervous system responses to exercise in chronic pain and how it may
be possible to enhance the EIH response to improve patient outcomes [87].
Physical rehabilitation is not the only treatment approach to show mostly small to moderate
effects on outcomes. Psychological treatments for chronic musculoskeletal pain show similar effect
sizes despite a large number of clinical trials available [88]. Few trials have investigated psychological
treatments for neck pain, but based on the chronic pain literature as a whole, it would be expected that
similar small effects would also be found. Interestingly, recent calls have been made from the psychology
field to consider the body as well as the brain when considering painful conditions. These authors
call this ‘embodied pain’ defined by the premise that cognition extends beyond the brain so that an
ever-changing body is at the core of how experiences are shaped such as by the unconscious workings
of the immune system or the collaborative efforts made to avoid movement [89]. Whilst it is very early
days, efforts to combine psychological treatment with physical exercise (“body”) treatment for neck
pain may show greater effects than either treatment alone [21], warranting further investigation.
Many reviews of musculoskeletal pain call for further research to identify who does or does
not respond to treatment [90,91]. It would be fair to say that little progress has been made in this
direction for any condition including neck pain. To date, clinical trials have not been able to identify
factors associated with treatment response. An early under-powered RCT of exercise for chronic WAD
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J. Clin. Med. 2019, 8, 1219
reported that patients with cold and mechanical hyperalgesia were less likely to respond to exercise [65],
but this result could not be replicated in a larger adequately powered study [66]. Similarly, no trials
investigating moderating factors on treatment effect for non-traumatic neck pain were identified. Such
knowledge would facilitate more individualized patient care.
The development and testing of innovative methods to include lifestyle interventions for neck
pain is needed. It is known that many lifestyle factors are associated with chronic musculoskeletal pain
including physical activity [60], sleep [92], smoking [93], stress [94,95], and possibly diet [96]. At the
current time, it is not known if addressing these factors will prevent the development of neck pain or
the transitions to recovery once an injury has occurred [97].
Other areas requiring research and clinical attention include the development and implementation
of modern methods of treatment delivery, in order to enhance access to treatment. Technology assisted
methods, such as telehealth, have been successfully used in the rehabilitation of conditions, such as
stroke [98] and post orthopaedic surgery [99], and show promise for the delivery of psychological
treatment. Such approaches have not been readily taken up in musculoskeletal pain practice, perhaps
due to the perception that passive hands-on treatment is required. However, the evidence dictates
that passive treatment is not essential for neck pain conditions. Rather, active treatment approaches
that improve patient self-efficacy are preferable due the stronger evidence base and these could be
delivered in more innovative ways than the traditional face-to-face sessions.
Key messages:
• Strengthening exercises of the neck and upper quadrant have a moderate effect on neck pain in
the short-term. This conclusion is based on moderate quality evidence.
• Other exercise approaches demonstrate small effects based mostly on low quality evidence.
• Reassurance/advice/education generally show small effects based on low to moderate
quality evidence.
• Psychological treatments alone have small effects based on very low to moderate quality evidence.
• Combined psychological and physical treatments delivered by physiotherapists may be
more effective.
• Clinical guidelines are mostly based upon low to moderate quality evidence or consensus, so
future research will likely change these conclusions.
• Clinicians should consider the limitations of the evidence regarding rehabilitation for chronic neck
pain, and as such broadly follow clinical guidelines; however, adapt treatment to each patient
as appropriate.
Finally, and by no means the least important, is that improved understanding of biological
processes underlying neck pain is required as this will provide direction for new and innovative
treatments. There is evidence available indicating impaired immune responses in WAD and neck
arm pain [100], some evidence of quantitative imaging biomarkers [101] and emerging data of genetic
variants of stress biomarkers associated with non-recovery after whiplash injury [102].
Author Contributions: M.S. conceived the content, wrote the paper and approved the final version. R.M.J.d.Z.
and S.F.F. contributed and approved the final version of the paper. I.C. conceived the design of the paper and
approved the final version of the manuscript.
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Journal of
Clinical Medicine
Review
Best Evidence Rehabilitation for Chronic Pain
Part 5: Osteoarthritis
David Rice 1,2, *, Peter McNair 1 , Eva Huysmans 3,4,5,6,7 , Janelle Letzen 8 and Patrick Finan 8
1 Health and Rehabilitation Research Institute, Auckland University of Technology, Auckland 1142,
New Zealand; peter.mcnair@aut.ac.nz
2 Waitemata Pain Service, Department of Anaesthesiology and Perioperative Medicine,
Waitemata District Health Board, Auckland 1142, New Zealand
3 Pain in Motion International Research Group; Eva.Huysmans@vub.be
4 Department of Physiotherapy, Human Physiology and Anatomy, Faculty of Physical Education &
Physiotherapy, Vrije Universiteit Brussel, 1090 Brussel, Belgium
5 Department of Public Health (GEWE), Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel,
6 I-CHER, Interuniversity Center for Health Economics Research, 1090 Brussels, Belgium
7 Department of Physical Medicine and Physiotherapy, Universitair Ziekenhuis Brussel,
8 Department of Psychiatry & Behavioral Sciences, Johns Hopkins University, Baltimore, MD 21287, USA;
jletzen1@jhmi.edu (J.L.); pfinan1@jhu.edu (P.F.)
* Correspondence: david.rice@aut.ac.nz
Received: 14 September 2019; Accepted: 30 September 2019; Published: 24 October 2019
Abstract: Osteoarthritis (OA) is a leading cause of chronic pain and disability in older adults, which
most commonly affects the joints of the knee, hip, and hand. To date, there are no established disease
modifying interventions that can halt or reverse OA progression. Therefore, treatment is focused on
alleviating pain and maintaining or improving physical and psychological function. Rehabilitation is
widely recommended as first-line treatment for OA as, in many cases, it is safer and more effective
than the best-established pharmacological interventions. In this article, we describe the presentation
of OA pain and give an overview of its peripheral and central mechanisms. We then provide a
state-of-the-art review of rehabilitation for OA pain—including self-management programs, exercise,
weight loss, cognitive behavioral therapy, adjunct therapies, and the use of aids and devices. Next, we
explore several promising directions for clinical practice, including novel education strategies to target
unhelpful illness and treatment beliefs, methods to enhance the efficacy of exercise interventions,
and innovative, brain-directed treatments. Finally, we discuss potential future research in areas,
such as treatment adherence and personalized rehabilitation for OA pain.
Keywords: osteoarthritis; musculoskeletal pain; rehabilitation medicine; physiotherapy; psychology;

non-pharmacological
1. Introduction
Osteoarthritis (OA) is the most common form of arthritis and a leading cause of chronic pain
and disability, affecting ~250 million people worldwide [1]. OA can occur in any synovial joint, but
the knee, hip, and joints of the hand are most commonly affected [2,3]. Important risk factors for the
development of OA include increasing age, female gender, previous joint trauma, and (as yet largely
unidentified) genetic factors [2,4]. In addition, increased mechanical stress on the joints caused by
factors, such as malalignment [2], increased body weight [5,6], and manual work [7–9], also play an
important role. While the signature characteristic of OA is a loss of articular cartilage, it is apparent that

J. Clin. Med. 2019, 8, 1769
many other joint structures can become affected as the disease progresses, including the subchondral
bone, fibrocartilage, capsule, ligaments, synovial membrane, and periarticular muscles [10].
1.1. OA Pain Presentation

Pain is the primary symptom that motivates people with OA to seek medical attention and it is
associated with functional limitations [11–13], emotional distress [14,15], fear of movement [16–18],
sleep problems [15,19], fatigue [15,20], and an overall marked reduction in quality of life [21,22]. Joint
pain might also have direct neuromuscular consequences, including muscle weakness [23], impaired
muscle force control [24], and gait adaptations [25], some of which may affect joint loading [26,27] and
increase the risk of further pain and structural deterioration [28–30].
Individuals with symptomatic OA commonly report pain in response to activities of daily living
that involve movement or mechanical loading of the affected joint, such as walking across the room,
getting up from sitting, or opening a jar [31]. Pain at rest and night pain are also frequently reported [31].
The painful joint(s) is commonly described as more sensitive to touch and pressure [32] and in some
cases, changes in temperature [33,34]. Two distinct types of joint pain are commonly reported—a
dull background aching, throbbing pain, and a sharp, stabbing pain that is intermittent but more
severe [31,35]. In knee OA, specifically, this intermittent, sharp pain often arises unpredictably and is
associated with giving way or locking of the knee [31]. A minority of people with OA [36–38] describe
pain qualities, such as burning, shooting, or electric shocks, and more recent evidence shows that some
describe perceptual disturbances, including feeling as if their painful limb is altered in size [39–41],
missing [32,42], or difficult to control [39,42].
OA pain is often described as highly variable, fluctuating in intensity both within and between
days [43–45]. In the long-term, the natural course of OA pain also varies across individuals. When
reassessed over several months or years, many people with OA (35–60%) report a more or less
consistent joint pain that does not markedly change over time [46–48]. For others, pain is described as
consistently worsening, progressing from a predominantly load-dependent intermittent pattern of
pain, to a more constant, severe pain [35,49]. Conversely, ~12–30% of people report sustained lessening
of pain intensity over several years [47,50,51]. Thus, although OA has traditionally been thought of as
a progressive condition, the evidence suggests that long-term worsening of pain is far from inevitable.
1.2. Mechanisms of OA Pain

Historically, OA pain has been viewed as a symptom, being driven by the activation of articular
nociceptors in response to structural damage of the joint [52,53]. While joint nociception is one
important factor contributing to OA pain, interdisciplinary research has revealed that OA pain is better
understood within a biopsychosocial framework [54–56]—being influenced by a complex array of
interacting factors.
1.2.1. Peripheral Mechanisms of OA Pain

Notably, articular cartilage is aneural, and therefore cannot generate nociception [57]. In contrast,
other joint structures, such as the subchondral bone, periosteum, ligaments, capsule, synovium,
and parts of the meniscus are richly innervated by nociceptors [58,59]. Despite this, demonstrating
a strong link between joint structural deterioration and OA pain has proven to be elusive. For the
individual person with OA, there does not appear to be a meaningful relationship between the
structural changes that were observed on x-ray and the intensity of the pain experience [60,61]. At a
population level, the relationship is somewhat stronger, with those who have severe radiographic
OA more likely to experience frequent pain [57,62,63]. However, as many as 75–80% of community
dwelling adults with evidence of radiographic OA do not experience frequent joint pain [64,65], while,
conversely, as few as 10–15% of people who experience frequent joint pain have definite radiographic
evidence of OA [60,64,65]. Furthermore, the radiographic progression of OA can be discordant with
changes in joint pain [48,66].
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J. Clin. Med. 2019, 8, 1769
The relatively poor relationship between radiographic findings and OA pain can be partly
explained by the lack of sensitivity of x-ray to joint structural changes, particularly in soft tissue and
subchondral bone [56,67]. Thus, several studies have examined the relationship between joint MRI
features and OA pain. In recent systematic reviews of studies involving people with radiographically
established knee OA [68,69], two MRI findings have been consistently associated with both incident
joint pain and worsening OA pain—bone marrow lesions (BMLs) and synovitis. BMLs are ill-defined,
hyperintense marrow signals on fluid-sensitive, fat-suppressed MRI [70,71]. While still unclear, it is
thought that BMLs may trigger nociception through microfracture of the subchondral bone, an increase
in intraosseous pressure and/or neoinnervation accompanying vascular in growth [71–73]. With respect
to synovitis, several inflammatory molecules directly activate chemosensitive nociceptors in the joint,
while others also produce potent, long lasting decreases in the firing threshold of nociceptors and
increase their spontaneous discharge, a process that is known as peripheral sensitization [58,59]. Thus,
synovitis, and the accompanying peripheral sensitization, may substantially increase joint nociceptor
discharge, both at rest and during movement. While once considered a non-inflammatory condition,
there is now compelling evidence that synovitis is a common feature of OA [74].
1.2.2. Central Mechanisms of OA Pain

Despite advances in our understanding of important sources of joint nociception, it is evident
that joint MRI features can also be discordant with pain. For example, at least one abnormal joint MRI
feature can be found in >80% of pain-free community dwelling adults [67]. Notably, MRI identified
synovitis might be present in ~30–35% of pain-free individuals [67,75], while BMLs may be observed
in ~30–50% of people who are pain free [75–77] and, even in those with established OA, progression or
resolution of synovitis [78] and BMLs [79] are not always related to changes in pain. These findings
suggest that other factors also play an important role in determining individual differences in OA
pain severity. In this regard, extensive preclinical evidence exists that, in the presence of ongoing joint
nociception, a maladaptive gain of neural signaling in the central nociceptive pathways within the
spinal cord and brain occurs in animal models of arthritis [80–83], a process that is known as central
sensitization. Importantly, central sensitization results in sensory input being strongly amplified when
it reaches nociceptive pathways at the level of the spinal cord and brain [84], thereby increasing the
frequency, severity, and spread of pain [85–87]. In recent decades, mounting evidence from human
studies suggests that central sensitization is evident in at least a subgroup of people with OA [88],
is an important driver of pain severity [85,87], and at least partly explains the discordance between
pain intensity and joint structural changes [89]. In addition, several neuroimaging studies have now
demonstrated altered brain structure and brain activation patterns in people with symptomatic OA.
Commonly, limbic areas of the brain are more active in people with OA than in controls [90–94],
both at rest and in response to standardized painful stimuli. In addition, changes in gray matter
volume [93,95,96] and white matter integrity [96] have been shown in several brain regions important
to nociceptive processing.
It is now well established that psychosocial and lifestyle factors (e.g., sleep) play an important
role in amplifying or attenuating the pain experience [97,98], and may be involved in the initiation and
maintenance of central sensitization [98–102]. These factors can also have an important influence on
disability, independent of their effect on pain [103–106]. For example, sleep problems are common in
OA, with at least 50% of individuals reporting difficulties in initiating or maintaining sleep [19,107].
The interrelations between sleep and pain have been well characterized over the past two decades,
with epidemiological, experimental, and clinical research providing broad support for a bidirectional
relationship [98]. Consistent with these findings, a number of studies have linked sleep problems with
increased pain and pain sensitivity among individuals with OA [108–112], which suggests that sleep
could be an important treatment target for reducing OA pain—although clinical trials have not always
supported that premise [113].
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As many as 40% of people with OA have anxiety, depression, or both, as compared to 5–17% in the
general population [114]. OA pain and depressive symptoms interact in a recursive cycle, with each
contributing to increased fatigue and disability, which may lead to pain worsening over time [20].
Furthermore, in a large sample of pain-free adults, high anxiety was found to predict new onset joint
pain over a 12-month follow up period [115] and it was associated with increased pain sensitivity
in people with established knee OA [115]. Similarly, people with OA who had the highest levels
of psychological distress and pain vigilance showed a generalized increase in pain sensitivity [116],
while higher levels of pain catastrophizing have been associated with a long-term worsening of OA
pain [117].
Conversely, resilience characteristics may offset maladaptive psychosocial factors. For example,
increased positive affect in people with knee OA predicts lower joint pain intensity and it is associated
with attenuated temporal summation [118], a measure of amplified central nociceptive processing.
Similarly, dispositional optimism is associated with lower depression symptoms and greater life
satisfaction in people with OA [119], while higher levels of self-efficacy are associated with long-term
stability or improvement in OA pain [117]. Finally, more social support has been associated with
reduced pain intensity, less distress, and greater activity levels amongst those with chronic pain
generally [120,121], and in people with OA specifically [122], while the OA pain and depression
symptoms are less strongly correlated in the presence of social support [119].
1.3. Summary and Aims

OA pain involves a complex interplay of mechanisms, some of which relate to the underlying
joint pathology and some of which are distinct—relating to the altered processing and interpretation
of nociception in the central nervous system. To date, there are no established disease modifying
interventions that can halt or reverse OA related cartilage loss or disease progression. Therefore,
treatment is focused on alleviating pain and maintaining or improving physical and psychological
function. Rehabilitation is widely recommended as first-line treatment for OA in evidence based
clinical guidelines [123–125], as it is safer and, in many cases, more effective at reducing pain than
the best established pharmacological interventions [126,127]. This paper provides a state-of-the-art
overview of rehabilitation interventions for OA pain. In the sections below, we review the best evidence
for rehabilitation—including self-management programs, exercise, weight loss, cognitive behavioral
therapy, adjunct therapies, and the use of aids and devices. Next, we explore several promising
directions for clinical practice, including novel education strategies to target unhelpful illness and
treatment beliefs, methods to enhance the efficacy of exercise and innovative, brain-directed treatments.
Finally, we discuss potential future research in areas, such as treatment adherence and personalized
rehabilitation for OA pain.
2. State-of-the-Art Rehabilitation
In this section we focus on synthesizing evidence from international treatment guidelines,
meta-analyses, systematic reviews, and, at times, recent randomized controlled trials. A non-systematic
search of the literature was performed in PubMed, Scopus, and Google Scholar using the following
search terms: rehabilitation, exercise, non-pharmacological, conservative, osteoarthritis, and pain,
in order to achieve this. Where appropriate, we used ‘systematic review’, ‘meta-analysis’ and
‘randomized controlled trial’ filters. Additionally, several international treatment guidelines from the
last decade were sourced and utilized.
Importantly, much of the evidence discussed in this section comes from studies in knee OA and,
to a lesser extent, hip and hand OA. There may be key differences in the optimum rehabilitation
strategies that were employed according to the joint(s) affected by OA. Where possible, we attempt to
provide examples where the strength of evidence or recommendations differ according to the joint
involved. However, until such time, as a sufficient number of high-quality studies are performed in
people suffering from OA at other joints, some extrapolation from the available literature is necessary.
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Furthermore, it is important to emphasize that the overall quality of the evidence considerably
varies across interventions (Table 1). Where possible, we attempt to highlight the quality of the evidence
in each section, as indicated in recent systematic reviews and international treatment guidelines. Finally,
the nature of many of the treatments discussed means that the effective blinding of the intervention is
difficult or, in some cases, impossible to achieve. Thus, as with any intervention, part of the therapeutic
effect described is likely to be non-specific in nature.
2.1. Self-Management Programs

Given that OA is a chronic disease, its symptoms require long-term, habitual management.
A passive coping style, through which people become behaviorally inhibited and avoid taking an
active role in self-managing their pain, has been consistently related to poorer outcomes across
various chronic pain disorders [128–130], including OA [131,132]. Several OA treatment guidelines
recommend self-management interventions as a core component in the effective management of
OA [123,133,134]. The notion that expectancy, belief, and motivation shape the pain experience and
the accompanying behaviors that contribute to either chronic pain adaptation or disability is critical
to the concept of self-management. Self-management interventions are programs that aim to teach
people to take an active role in managing their condition through any combination of education,
behavior change, and psychosocial coping skills [135]. For example, these interventions can include
modules providing information regarding the health condition, healthcare resource utilization, stress
management techniques, physical exercises, and interpersonal problem-solving skills. These programs
can be heterogeneous in the implementation of specific strategies, but commonly try to counter
unhelpful illness and treatment beliefs and impart transferable skills that empower individuals to
effectively manage their symptoms long-term [136].
The existing evidence for self-management program efficacy in OA shows mixed outcomes.
A meta-analysis pooling results from 13 trials found an overall small beneficial effect of self-management
programs on pain reduction, but no significant impact on quality of life or physical function [137].
However, the authors found a specific pooled effect of pain reduction and quality of life improvement
for self-management programs that contained exercise programs, which suggests the latter might
be a key component for OA. Furthermore, Kroon and colleagues examined 29 studies comparing
education-specific self-management interventions to other interventions for adults with OA. The authors
found overall weak effect sizes for self-management programs that are focused on disease education
over other treatments [138], which suggests that current education strategies may be suboptimal.
Both reviews concluded that self-management programs vary widely in their content (e.g., focus on
managing OA symptoms vs. holistic well-being), duration (e.g., single session vs. ongoing, weekly vs.
monthly), and method of delivery (e.g., in-person vs. telehealth, individual vs. group, lay leader vs.
healthcare professional), limiting conclusive evidence for their efficacy.
2.2. Exercise
Regular exercise is considered to be a core treatment for OA and it is universally recommended
amongst treatment guidelines for all individuals with OA, regardless of their individual
presentation [126,139,140]. Exercise has a number of potential benefits, including improving
pain [126,141,142], physical function [143], and mood [144], as well as decreasing the risk of secondary
health problems, including cardiovascular, metabolic, neurodegenerative, and bone disorders [145].
Exercise likely reduces OA pain by several different mechanisms, including increased central nervous
system inhibition [146,147], local [148] and systemic [149] reductions in inflammation, psychosocial
effects [150], and biomechanical effects at the affected joint [151].
Exercise for OA might include low impact aerobic exercise, such as walking or cycling, resistance
training for muscle strengthening, stretching, and other forms of exercise, such as Tai Chi or
Yoga. Importantly, exercise has very few adverse effects [152], does not appear to accelerate joint
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degeneration [152–154], and has similar or better effect sizes for OA pain as compared to commonly
used analgesics, such as acetaminophen and non-steroidal anti-inflammatory drugs (NSAIDS) [126].
At this time, there is insufficient evidence to determine whether one type of exercise is
superior, with systematic reviews suggesting that several different types of exercise are effective
for OA [125–127,155]. Resistance training is the most studied type of exercise for individuals with
OA. The strongest evidence for pain relief and improvements in function exists in people with
knee and hip OA [141,142], with fewer high quality studies in hand OA [156]. Resistance training
interventions can be home or clinic based, and should be undertaken for at least 2–4 months in
order to maximize the clinical benefits [157]. Aerobic exercise is widely recommended in treatment
guidelines [123,124,126,133,134,158,159], effectively relieves OA pain [127], and it may have additional
benefits, such as promoting cardiovascular health and weight loss. However, the majority of RCTs
that were conducted in OA populations include interventions that are not solely aerobic but have
elements of strengthening and stretching to varying degrees [158]. Hence, their findings could be
viewed as supporting the inclusion of aerobic exercise within a wider program of exercise. Other forms
of exercise, such as tai chi, yoga, and whole body vibration, currently have less evidence to support
them, with low to very low quality evidence that shows both positive and negative effects [125,160].
Some guidelines [124,126] have made conditional recommendations concerning land-based versus
water-based interventions. Overall, there is greater support for land-based exercise that is based upon
both the magnitude of effects in RCTs and the quality of evidence [125]. However, some individuals
with hip or knee OA might be better suited or have a preference for water-based exercise for some
parts of their rehabilitation program [124].
For exercise to be most successful, it must be of sufficient volume to elicit adaptations that relieve
pain and improve physical function. Concerning resistance training, guidelines [157] highlight that
pain relief can occur, irrespective of the equipment (dynamometers, weights, bands) utilized, the type of
exercise (e.g., isokinetic, isotonic), and the muscle action (i.e., isometric, eccentric concentric) performed.
Despite such a range of options, consideration should be given within the overall program to those
exercises that more closely simulate the type of muscle activity utilized in the work tasks and/or
activities that are required in the individual’s daily life. Other parameters, such as the load, the number
of repetitions within a set, the number of sets performed per session, the rest intervals between sets,
and the frequency of sessions per week should all be carefully considered. For aerobic exercise,
the intensity, type of exercise, how it is performed (e.g., continuous or in intervals), and frequency
per week are all important. For aerobic and strengthening exercises, the suggested starting points
for these training parameters are well described in the ACSM public health guidelines [161], with a
recent clinical guideline [162] recommending these levels of exercise are embedded within standard
care in people with OA. Specifically, a minimum of 150 min. moderate intensity or 75 min. vigorous
intensity aerobic exercise per week is recommended (in bouts of at least 10 min). For resistance training,
two sessions per week, with two sets of eight to 12 repetitions at a load of 60% to 70% of one repetition
maximum can be recommended as a starting point [161]. A rest period of ≥48 h between resistance
training sessions is suggested in order to optimize muscle hypertrophy [161].
The need for personalized, individually tailored exercise programs while taking into account a
person’s exercise preferences has been highlighted [124,163], as these are considered more likely to
achieve long term exercise adherence [164]. Another key point concerning adherence is that education is
often needed to emphasize that appropriate levels of exercise are safe, and while pain exacerbations may
occur at times, these will reduce over the course of a training program [165] and people with OA will
continue to benefit from ongoing exercise. It is recommended [162] that exercise regimes be provided
by health care professionals with suitable backgrounds (e.g., physiotherapists) who regularly reassess
progress and modify training parameters to limit and manage symptom exacerbations. The importance
of progression has also been highlighted by Brosseau et al. [157] and Magni et al. [156], who noted that
the majority of trials that did not find positive results for an exercise intervention had not implemented
a program that continually reassessed and progressed the training volume over time.
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Concerning the overall duration of the exercise program, one could argue that exercise should
be considered as a lifestyle change and undertaken perennially. To date, most RCTs of exercise
interventions involving people with OA have been undertaken over a two to four month period with
few interventions extending past six months. While benefits can continue for several months, it is
well known from the literature related to athletic training that when training is stopped completely,
a detraining effect be observed within two to three weeks [166], and this decline steadily continues,
depending upon factors, such as age and physical activity level. Importantly, there is evidence [166] that
these declines in performance can be slowed with booster sessions that are undertaken less regularly
(e.g., one training sessions every one to two weeks for resistance and aerobic exercise). Booster sessions
may also be useful in promoting longer-term exercise adherence [167].
2.3. Weight Loss

Increased body weight is considered to be an important modifiable risk factor for the onset
and progression of pain and radiographic findings [168–170] of OA, specifically at the knee and
hip [124,171–173]. In symptomatic knee OA, this risk is doubled with every 3–4 kg/m2 increase in Body
Mass Index (BMI) [168]. Furthermore, obesity is associated with a systemic pro-inflammatory state
that may accelerate joint degeneration [174] and increase the sensitization of the nociceptive system,
thereby enhancing OA pain [175]. As a result, weight loss interventions are recommended by several
international treatment guidelines for OA as part of the core treatment for people with knee and/or hip
OA that are overweight or obese [123,124,126,133,134,140,159,169,176–180]. Furthermore, education
regarding the importance of maintaining a healthy lifestyle and body weight is recommended for all
people with OA [124].
Although a consensus regarding the BMI cut off for determining the target population for weight
loss programs is lacking [180], weight loss is typically recommended in individuals presenting with
symptomatic OA and a BMI ≥ 25 kg/m2 [124,133,169,177] (pre-obesity BMI value, as defined by the
World Health Organization [181]). Care should be taken when advising weight loss to older people
(aged > 65 years) to ensure the maintenance of lean body mass and bone density [124,182].
The importance of weight loss programs is supported by moderate to high quality
evidence reporting improvements in pain and disability after weight loss in people with knee
OA [177,183–185]. More recently, a reduction in systemic inflammatory biomarkers has also been
observed [186]. Ideally, weight loss interventions should comprise a combination of dietary advice and
exercise [124,177,184,187–190], including explicit individual weight loss goals and problem solving
regarding how to reach these goals [159,184,191,192]. The benefits of weight loss interventions are dose
dependent—with higher amounts of weight loss resulting in larger benefits—starting at a minimum of
5–7.5% body weight loss [124,184,185,193].
Although the evidence for weight management programs is generally limited to knee OA,
the systemic health benefits of weight loss and maintaining a healthy body weight are not negligible.
Therefore, weight loss principles are most likely transferable to people with hip OA [134], in which
being overweight is known to be a risk factor [124,171], and possibly also to individuals with OA in
other joints [123,176].
2.4. Cognitive Behavioral Therapy

Cognitive behavioral therapy (CBT) is increasingly recognized as a valuable intervention for
OA pain. A recent guideline [124] recommends CBT for selected people with knee and/or hip OA,
particularly those with psychosocial comorbidities. Another recent treatment guideline specifically
focused on arthritis pain management [125] concluded there is now moderate evidence supporting
CBT for OA pain and recommended that appropriately selected individuals should receive both
psychological and sleep interventions. CBT for pain generally involves the identification and facilitation
of individually specific behavioral goals that promote activity and social engagement while minimizing
withdrawal and guarding. Cognitive barriers to engagement in adaptive behaviors (e.g., pain
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catastrophizing) are also identified and systematically challenged in the course of CBT. While CBT for
pain has been extensively investigated in a variety of chronic pain disorders, relatively fewer trials are
available for OA [194]. A recent systematic review and meta-analysis identified 12 RCTs that examine
psychological interventions in an OA population [195]. While heterogeneous in the focus of their
treatment, overall, these studies demonstrated small reductions in pain and fatigue and moderate
to large improvements in self efficacy and pain coping. Interestingly, despite focusing on non-pain
symptoms, several RCTs that involve CBT interventions have also demonstrated modest efficacy for
improving OA pain. For example, an online CBT intervention for depression in people with knee
OA and comorbid depression significantly reduced depression symptoms, but also demonstrated a
medium-sized effect on OA pain and function relative to treatment as usual [196]. Similarly, CBT for
insomnia has been tested in several different cohorts of people with knee OA and comorbid insomnia.
Smith et al. [197] demonstrated that CBT for insomnia improved wake after sleep onset—a key marker
of sleep disruption—among people with OA. Statistically significant reductions in pain severity were
observed through six-month follow-up, and improvements in wake after sleep onset predicted reduced
pain at follow-up. Small to medium sized effects on pain were observed in another RCT of CBT for
insomnia in people with knee OA and comorbid insomnia [198], as well as a larger population-based
RCT of CBT for insomnia in people with knee OA recruited from primary care clinics [199]. Finally,
Vitiello et al. [200] conducted a three-arm trial comparing CBT for pain with CBT for comorbid pain and
insomnia symptoms and an education control in people with OA and comorbid insomnia. Interestingly,
the mean pain levels were not significantly improved in any treatment condition by post intervention.
However, in subgroup analyses, those individuals who had clinically meaningful improvements in
insomnia symptoms (≥30% reduction) by post-intervention (two months) demonstrated significant
long-term reductions in pain at both nine and 18-month follow-up. Thus, there is growing evidence
that CBT interventions, whether directed at pain or at other problems, such as depression or sleep, can
produce clinical benefits and should be considered in appropriate individuals.
2.5. Adjunct Treatments

Several OA treatment guidelines include recommendations regarding the use of adjunct treatments,
such as manual therapy, thermal modalities, acupuncture, and electrotherapies [123,124,126,133].
The quality of evidence used in forming these recommendations is generally low quality, with a high
risk of bias, and it is apparent that more studies involving these interventions are needed before
strong conclusions can be drawn. Manual therapy (that may include joint mobilization/manipulation
and massage) is generally not recommended as a stand-alone treatment [123,124,133,178], but a short
course of manual therapy [124], provided as an adjunct treatment to facilitate engagement in active
strategies, such as exercise, is recommended by several guidelines [123,124,178] and might enhance
pain relief compared to exercise alone [201].
The use of thermal modalities, such as superficial heat or cold, may provide short-term relief of
symptoms and are low cost, low risk interventions that can be incorporated into self-management,
and are therefore widely recommended as adjunct treatments in several guidelines [123,124,178],
despite low quality evidence supporting their use.
Some treatment guidelines recommend acupuncture, particularly for knee OA [178], but others
recommend against it [123,124,133], as well conducted systematic reviews have typically shown that the
benefits as compared to placebo are small and of questionable clinical importance [202,203]. There may
be value over usual care for individuals with OA who have positive treatment expectations regarding
acupuncture, although much of the clinical benefit may be due to non-specific effects [204].
The evidence for electrotherapies is mixed and it is limited by low quality studies with short
follow up times. A recent systematic review [205] suggests that interferential and high frequency TENS
may have some benefit, while evidence is generally lacking for other modalities. Several treatment
guidelines recommend using TENS as an adjunct treatment [123,124,163,178]. The portability of TENS
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units, their relatively low cost, and their ability to be used at home as part of a self-management
strategy or in combination with exercise makes this form of electrotherapy particularly attractive.
2.6. Aids and Devices

A large range of braces, insoles, and splints are available and marketed for individuals with OA.
In general, these devices are designed to produce mechanical effects that decrease load on the OA
affected joint or offer additional sensory input that may enhance proprioception and joint stability.
There is generally low to very low evidence supporting their use and very little information that can be
used clinically to determine which device may or may not be appropriate for a given individual [164].
Unloading braces have metal and soft materials, which are located or positioned to reduce joint
forces during gait activities, particularly in knee OA. A recent treatment guideline [124] recommended
that valgus unloading braces should not be offered for medial compartment OA. For lateral compartment
OA, a decision to recommend either for or against the use of a varus unloading brace could not be
made. These findings were similar to other treatment guidelines [123,125], where low quality evidence
provided unclear to positive support of braces. Individuals with lower limb musculoskeletal conditions
have long used canes (walking sticks). Based on low and very low evidence levels, these devices may
be useful for some individuals with knee and/or hip OA, and they were conditionally recommended
by some treatment guidelines [123,124].
For other types of support (e.g., elastic bandages/soft braces/tape) that are thought to primarily
improve joint proprioception, a EULAR guidelines group [125] indicated that while there was low
quality evidence, it was generally positive. With hand OA, splints are often utilized to manage pain,
alignment, and instability issues, particularly at the thumb. Long term use (>3 months) of splints
has been recommended for pain that is associated with thumb OA [163,206], with short term use
and use in other joints considered to be ineffective [125,206]. Overall, the evidence supporting these
recommendations is considered low quality.
Regarding footwear for lower limb OA, a recent treatment guideline [124] has recommended
that unloading shoes, minimalist footwear, and rocker-sole shoes should not be offered to individuals
with knee OA at this time, due to limited evidence supporting their efficacy. It was also thought
that high heel shoes should be avoided but that shoes with additional shock absorbing properties
might be suggested to some people. The support for shoe inserts is mixed, with recent treatment
guidelines [124,125], finding low to very low evidence supporting lateral wedge shoe insoles for medial
compartment OA and medial wedge insoles for lateral compartment OA with benefits ranging from
unclear to positive.
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Table 1. Best evidence table for the rehabilitation of people with osteoarthritis: Summary of the evidence and recommendations for practice.
Main Profession(s)
Intervention LoE Summary of Evidence Recommended by Recent Treatment Guidelines Authors’ Recommendations for Practice
Involved
Uncertain/Not
Yes [Ref] No [Ref]
Included [Ref]
Self-Management Programs
ACR [178] Provide education to enhance understanding of OA and its treatment in
Low to moderate quality evidence of no or
EULAR knee & hip [159] order to counter misconceptions that OA inevitably progresses, cannot be
small positive effect on pain, function and General practitioner OR
NICE [164] treated and that symptoms are closely related to imaging findings.
J. Clin. Med. 2019, 8, 1769
quality of life. psychologist OR

1A OARSI knee [126] - RACGP [124] Encourage active self-management and positive behavioral changes such as
Large degree of variability in delivery. physiotherapist OR
PANLAR [163] regular exercise, weight loss, good sleep hygiene and activity pacing.
Self-management programs that include internet based
EULAR hand [207] Avoid use of language such as “wear and tear” and “bone on bone” as this
exercise may be more effective.
EULAR pain [125] may perpetuate unhelpful illness and treatment beliefs.
Exercise
A combination of resistance training and low impact aerobic exercise should
Moderate to high quality evidence of a be provided and tailored to the impairments, functional requirements and
ACR [178]
positive effect on pain and function in hip preferences of the individual.
EULAR knee & hip [159]
and knee OA that is sustained for several Consider water-based exercise in individuals who prefer it, or cannot
NICE [164]
months. Low quality evidence for hand OA. tolerate land-based exercise.
Physiotherapist OR OARSI knee [126]
1A Several different types of exercise may be - - Provide education that exercise is safe and provide reassurance about
exercise physiologist PANLAR [163]
effective (not clear which is best). potential symptom exacerbations.
EULAR hand [207]
Programs that progress exercise volume Exercise should continue for at least 8 weeks and training volume
EULAR pain [125]
over time and deliver higher overall doses progressed regularly in order to maximize benefits.
RACGP [124]
of exercise may be more effective. Provide booster sessions to minimize detraining effects and enhance long
term exercise adherence.
Weight Loss
Target a minimum weight loss of 5–7.5% of body weight in all people with
104
knee and/or hip OA who have a BMI of ≥ 25 kg/m2 . Greater weight loss will
ACR [178] likely result in increased benefit.
EULAR knee & hip [159] Provide education about the importance of maintaining a healthy body
Moderate to high quality evidence of dose
Dietician OR NICE [164] weight to people with a BMI of < 25 kg/m2 .
dependent improvements in pain and
physiotherapist OR Explicit weight loss goals and problem solving on how to achieve those
1A function with weight loss in knee OA, with - EULAR hand [207]
psychologist OR OARSI knee [126] goals should be planned in a patient centered, collaborative manner.
presumed benefits for hip OA and possibly
general practitioner PANLAR [163] Consider a combination of individualized strategies such as regular weight
other joints.
EULAR pain [125] monitoring, increased physical activity, social support, meal plans, limiting
RACGP [124] portion size, reducing fat and sugar intake, time restricted feeding and
addressing behavioral triggers to eating (e.g., stress, poor sleep).
Combining weight loss with regular exercise will increase its benefits.
Table 1. Cont.
Main Profession(s)
Involved
Uncertain/Not
Yes [Ref] No [Ref]
Included [Ref]
Cognitive Behavioral Therapy
Low to moderate quality evidence that CBT EULAR hand [207] Consider CBT if significant psychosocial comorbidities (e.g., depression)
has small positive effects on OA pain and PANLAR [163] exist that may interfere with effective pain management and rehabilitation.
ACR [178]
fatigue and moderate to large positive Psychologist OR OARSI knee [126] Consider CBT based sleep interventions for people with OA who have
J. Clin. Med. 2019, 8, 1769
1A EULAR pain [125] -

effects on self efficacy and pain coping. internet based NICE [164] co-morbid sleep problems.
RACGP [124]
Overall mixed (no to medium positive) EULAR knee & hip Consider CBT if psychological factors such as fear of movement and pain
effects on pain in trials of CBT for insomnia. [159] catastrophizing are a barrier to physical function and engaging in exercise.
Adjunct Treatments
EULAR knee & hip
RACGP knee & hip [124]
Low quality evidence that manual therapy [159]
Physiotherapist OR ACR [178]
Manual alone or in combination with exercise has OARSI knee [126] Consider providing a time-limited course of manual therapy as an adjunct
1A osteopath OR NICE [164]
therapy short term positive effects on pain and PANLAR to exercise if the individual finds it beneficial.
chiropractor (all as an adjunct
function EULAR hand [207]
treatment only)
EULAR pain [125]
PANLAR [163]
(stand-alone)RACGP EULAR knee & hip
Low quality evidence that thermal Self-management OR
Thermal knee & hip [124] [159] Consider the use of local hot or cold packs as a pain self-management
1B modalities may provide short term positive physiotherapist OR
modalities ACR [178] EULAR hand [207] strategy or as an adjunct to exercise if the individual finds this beneficial.
effects on pain general practitioner
NICE [164] EULAR pain [125]
(all as an adjunct only)
EULAR knee & hip
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[159]
Low to moderate quality evidence of mixed NICE [164]
Acupuncture is generally not recommended for the treatment of OA.
(no to medium positive) effects on pain RACGP
Acupuncture 1A Acupuncturist ACR [178] OARSI knee [126] Consider a time-limited course of acupuncture as an adjunct treatment only
compared to sham knee & hip
PANLAR [163] if the individual has positive treatment expectations.
acupuncture interventions. [124]
EULAR hand [207]
EULAR pain [125]
EULAR knee & hip
Low quality evidence that interferential and ACR [178]
Self-management OR [159]
high-frequency TENS may have positive NICE [164] Consider the use of TENS as a pain self-management strategy or as an
Electro-therapy 1A physiotherapist OR OARSI knee [126]
effects on pain and function. Limited PANLAR [163] adjunct to exercise if the individual finds this beneficial.
general practitioner EULAR hand [207]
evidence for other forms of electrotherapy. RACGP knee & hip [124]
EULAR pain [125]
Table 1. Cont.
Main Profession(s)
Involved
Uncertain/Not
Yes [Ref] No [Ref]
Included [Ref]
Aids and Devices
ACR [178]
Limited, low quality evidence that RACGP
Unloading NICE [164] EULAR knee & hip
1B unloading braces have no effect on pain or Not discipline specific knee & hip Unloading braces are not recommended in the treatment of OA.
braces OARSI knee [126] [159]
J. Clin. Med. 2019, 8, 1769
function in knee OA [124]

EULAR hand [207]
Consider the use of a cane (walking stick) in people with lower limb OA if
Limited, low quality evidence that the use of ACR [178]
the individual finds this beneficial or has notable problems with balance
Cane (walking a cane has positive effects on pain and EULAR knee & hip [159]
2B Not discipline specific EULAR hand [207] and mobility.
stick) function in knee OA with possible benefits EULAR pain [125]
The cane should be used on the contralateral side and adjusted to the height
for other lower limb joints. RACGP knee & hip [124]
of the greater trochanter.
NICE [164] ACR [178]
Low quality evidence that soft braces have
OARSI knee [126] EULAR knee & hip Consider the use of a soft brace (e.g., neoprene brace, elastic sleeve) in
Soft braces 1A mixed (no to positive) effects on pain and Not discipline specific
PANLAR [163] [159] people with knee OA if the individual finds this beneficial.
function in knee OA
EULAR pain [125] EULAR hand [207]
Low quality evidence that long term use of ACR [178] EULAR knee & hip
splints have a positive effect on pain and NICE [164] [159]
Physiotherapist OR Consider the long term use (>3 months) of a splint for people with thumb
Splints 1A function for thumb OA only. Limited EULAR hand [207] RACGP knee & hip
occupational therapist OA only.
evidence that one type of splint is better PANLAR [163] [124]
than any other. EULAR pain [125] OARSI knee [126]
EULAR knee & hip [159] Specific footwear (e.g., minimalist footwear, rocker-sole shoes, unloading
Limited, low quality evidence that specific RACGP EULAR hand [207]
106
NICE [164] shoes) is not recommended in the treatment of OA.
Footwear 1B footwear has no benefit on pain and Not discipline specific knee & hip ACR [178]
EULAR pain [125] Consider the use of shoes with appropriate shock absorbing properties for
function compared to standard footwear. [124] PANLAR [163]
OARSI knee [126] people with lower limb OA.
Low quality evidence that medial wedge
shoe insoles may provide positive effects on
pain and function for lateral compartment ACR [178] Consider the use of medial wedge shoe insole for people with lateral
RACGP EULAR knee & hip
knee OA. Podiatrist OR NICE [164] compartment knee OA if the individual finds this beneficial.
Shoe Insoles 1B knee & hip [159]
Low quality evidence that lateral wedge physiotherapist OARSI knee [126] Lateral wedge shoe insoles are not recommended in the treatment of
[124] EULAR hand [207]
insoles for medial compartment knee OA PANLAR [163] knee OA.
have mixed (no to positive) effects on pain
and function
Level of Evidence (LoE): 1A: Systematic review of randomized controlled trials; 1B: Individual randomized controlled trials; 2A: Systematic review of cohort studies; 2B: Individual
cohort study or low quality randomized controlled trials; 3A: Systematic review of case-control studies; 3B: individual case-control study; 4: Case-series; 5: Expert opinion. Quality of
evidence is as reported in recent systematic reviews or international treatment guidelines. Abbreviations: LoE = Level of evidence; OA = osteoarthritis; Ref = Reference; CBT = Cognitive
behavioral therapy.
J. Clin. Med. 2019, 8, 1769
3.1. Improved Education Strategies to Address Maladaptive Pain-Related Beliefs

People with OA can display fear avoidance behaviors [16–18] that limit their engagement in
effective rehabilitation strategies, such as regular exercise. A recent Cochrane review [207] has
highlighted many of the unhelpful beliefs held by people with hip and knee OA that help to shape
these behaviors. Many people describe being confused about the cause of their pain and bewildered
by its variability and unpredictable nature [207]. Furthermore, as movement frequently increased
their pain, they worried that this might be doing their joint further harm and described avoiding
physical activity and exercise as a result [207]. These findings suggest a need for strategies tackling
these maladaptive beliefs and behaviors.
Pain neuroscience education is a cognitive-based intervention that is aimed at reconceptualizing
pain by de-emphasizing pathoanatomical content and focusing on other factors, such as the discordance
between imaging findings and pain, peripheral and central sensitization, cognition, mood and lifestyle
factors that may contribute to the development and persistence of pain, all within a biopsychosocial
framework [208,209]. The use of this educational strategy in people with chronic pain in order to change
pain related beliefs, improve health behaviors and—importantly—desensitize the central nervous
system, is supported by high quality evidence [209–211]. Although pain neuroscience education has
been studied in several chronic pain populations [211], the evidence in people with OA is still limited
and mainly focused on people undergoing knee arthroplasty [212,213]. In these studies, positive effects
of preoperative pain neuroscience education were found in terms of psychosocial measures (pain
catastrophizing [212] and kinesiophobia [212,213]), pressure pain thresholds [213], and peoples’ beliefs
regarding their scheduled surgery [213].
As the evidence suggests that current education strategies for OA have limited success [138],
a pain neuroscience approach might provide an alternative and more effective means of targeting
unhelpful illness and treatment beliefs, particularly at the beginning of a rehabilitation program.
This may help to reduce pain and psychological distress as well as facilitate engagement and adherence
in exercise-based interventions. Such an approach might be particularly effective if the pain-relieving
effects of exercise and its role in desensitizing the nociceptive system are specifically emphasized and
incorporated into the education session(s), as this has been shown to enhance positive expectations
and increase exercise induced pain relief [214].
3.2. Enhancing the Effectiveness of Resistance Training

The weakness of muscles adjacent to the painful joint(s) is a common feature of OA. Adequate
muscle strength is required for many activities of daily living [215,216] and muscle weakness is a
major factor contributing to OA related functional disability [217,218]. In the lower limb, muscles
may also have a protective role, attenuating mechanical loading of the OA joint during gait and other
activities [27,219]. There is some evidence that higher quadriceps muscle volume might protect against
incident knee pain and ongoing cartilage loss [29,30] and recent findings suggest that the magnitude
of quadriceps strength gains partially mediate the pain-relieving effect of resistance training in knee
OA [220]. Unfortunately, muscle strength gains during resistance training are often compromised by
arthrogenic muscle inhibition, an ongoing neural inhibition of muscle activation due to factors, such as
joint effusion, nociception, and sensory loss [23,221–223]. This problem is widely recognized in knee
OA [224], although arthrogenic muscle inhibition might also contribute to ongoing muscle weakness
at other joints [225–228]. Importantly, it has been shown in people with OA that adjunct disinhibitory
interventions, such as cryotherapy, TENS, and NSAIDS, can be used to reduce arthrogenic muscle
inhibition [229,230] and, when used in conjunction with resistance training, might enhance muscle
strength gains when compared to resistance training alone [230–232].
Another promising intervention that might enhance the efficacy of resistance training in OA is
blood flow restriction training. Blood flow restriction training utilizes an inflatable cuff or band to
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J. Clin. Med. 2019, 8, 1769
partially occlude blood flow in the exercising muscles. Importantly, blood flow restriction allows
exercise of very low load (e.g., 20–40% of 1RM) to produce significant gains in muscle strength and
size [233], seemingly due to exaggerated metabolic stress when training the muscle(s) under partial
occlusion. To date, blood flow restriction training has been largely applied in healthy populations [233],
but it is an attractive intervention for OA, as it has the potential to accelerate muscle hypertrophy and
strength gains while also notably reducing the mechanical load placed on the affected joint(s) during
training—thus potentially minimizing exercise-induced flares in joint pain. Preliminary evidence in
populations that are relevant to OA suggests that blood flow restriction training is associated with
less pain during exercise [234–236] and may produce similar [234–237] or greater [238] gains in muscle
strength than resistance training performed without blood flow restriction.
3.3. Brain Directed Treatments of Sensorimotor Networks

There is growing evidence of dysfunction in brain sensorimotor networks amongst people
with OA, with observations of widespread tactile hypoaesthesia [239], reduced tactile acuity [240],
body size distortions [41], neglect-like symptoms [42], altered primary somatosensory cortex
volume [96], impaired implicit motor imagery performance [42,241], and both disinhibition [242] and
reorganization [243] of the primary motor cortex. While the clinical implications of these changes are
yet to be fully elucidated, there is evidence that some might be important treatment targets for OA
pain. For example, recent RCTs provide preliminary evidence that non-invasive brain stimulation of
the primary motor cortex may reduce OA pain, either when delivered alone or in combination with
other interventions [244–247]. Furthermore, in other chronic pain conditions, sensory discrimination
training has been used to reverse deficits in tactile acuity that are similar to those that were observed in
OA [248,249]. These interventions have also been shown to reduce chronic pain intensity [248–251],
with the magnitude of pain relief being strongly correlated to improvements in tactile acuity [249,250]
and cortical sensory representation of the affected body part [250]. Finally, it has been shown that
presenting a multisensory illusion of the painful OA joint(s) stretching or shrinking can produce
immediate and, in some cases, substantial pain relief [40,252], and that this intervention can partially
correct distorted size perceptions of the OA affected limb [41]. While still in its infancy, the use of brain
directed treatments that target impaired sensorimotor networks is a promising clinical direction that
might have important future implications in the rehabilitation of OA pain.
4.1. Personalized Treatment

In recent years, a number of studies have attempted to identify several distinct OA pain
phenotypes or subgroups from a larger population [253–258]. The potential benefits of such an
approach include the identification of key prognostic factors that predict treatment response and,
ultimately, the development of more targeted treatments that are personalized to the individual and
their dominant pain mechanism(s). For example, individuals with OA who have more pronounced
central sensitization, as evidenced by increased temporal summation [259–264] and, in some cases,
widespread pain sensitivity [265] and reduced conditioned pain modulation [261,266] may experience
less pain relief and are at higher risk of persistent pain after peripherally targeted treatments, such as
NSAIDs or total joint replacement surgery.
The identification of relevant OA pain phenotypes may also lead to improved rehabilitation
strategies. For example, Fingleton et al. [267] have recently shown that the initial response to exercise
in people with knee OA varies according to the baseline function of their endogenous descending pain
inhibitory/facilitatory pathways—i.e., those with deficient conditioned pain modulation tended to
experience increased pain after both aerobic and resistance exercise, while pain was reduced in those
with intact conditioned pain modulation and in healthy controls. Studies such as this that explore
within-group differences in OA may allow for better identification of likely non-responders to treatment
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J. Clin. Med. 2019, 8, 1769
and facilitate the development of alternative, more personalized strategies (e.g., the combination of
centrally acting analgesics with exercise) to enhance clinical outcomes in these individuals.
Similarly, despite consistent evidence of the positive treatment effects of psychological therapies for
OA, there is a gap between the strength of evidence for process-oriented measures and core outcomes.
For example, whereas psychological therapies produce large effects on active coping, the effects on pain
and function tend to be smaller [268]. One reason for this discrepancy might be the fact that a portion
of people with OA have more pronounced central sensitization [89], which may be less responsive
to traditional CBT and related psychosocial therapies [269]. Lumley & Schubiner [269] have recently
proposed a novel treatment paradigm that is intended to target people with central sensitization by
performing a detailed intake assessment and tailoring treatment with pain neuroscience education,
cognitive therapy, mindfulness, behavioral desensitization, emotional expression, and interpersonal
communication skills. An initial RCT in fibromyalgia patients [270] showed that this treatment
approach outperformed traditional CBT in lowering the fibromyalgia symptoms and widespread pain.
Future work is needed to similarly evaluate the differential efficacy between this novel pain treatment
and traditional CBT for people with OA subtyped based on their degree of central sensitization.
4.2. New Ways of Understanding and Enhancing Treatment Adherence

Better adherence to rehabilitation interventions in OA is typically associated with greater symptom
improvement [196,271–273]. However, previous work has documented poor to adequate adherence
among this population [274–277]. Furthermore, current strategies that aimed at increasing adherence
are not uniformly effective. A meta-analysis of adherence interventions found significant improvements
in only 18 of the 42 included trials [278]. This low efficacy rate emphasizes the need for novel, more
potent interventions to promote adherence to rehabilitation programs. The predictors and mechanisms
of adherence to rehabilitation interventions in OA are not fully established. However, previous work
suggests that motivation is a consistent predictor of treatment adherence in OA and across chronic
pain conditions [279–284].
Although psychosocial factors predicting treatment motivation amongst those with chronic pain
have been probed, physiological mechanisms potentially subserving these processes have not been
examined. For example, a potentially important physiological mechanism of treatment motivation
is mesocorticolimbic function [285]. This neural system—colloquially referred to as “the reward
system”—has been extensively associated with motivational processes and reward learning in humans
and animal models [286–289]. On behavioral tasks, individuals with chronic pain demonstrated
altered reward learning [290–292] and reduced motivation [280,293] when compared to individuals
without pain. Factors, such as depression and opioid use, are likely to further compound these effects.
Neuroimaging data support these findings by demonstrating aberrant mesocorticolimbic system
structure [96,294] and function during pain relief—potentially reflective of attenuated rewarding effects
of analgesia [295–299]—and wakeful rest [300–302] among people with chronic pain.
It is possible that altered reward learning and attenuated rewarding effects of pain relief contribute
to reductions in treatment motivation and the resultant adherence to rehabilitation. Future studies
might examine the extent of the relationships among baseline treatment motivation, mesocorticolimbic
function, and engagement in adaptive rehabilitation strategies, such as regular exercise. This question
could be addressed while using a combination of neuroimaging, questionnaire, and ecological
momentary assessment (e.g., daily diary) data. Such an approach might inform the development of
adjunct interventions to bolster the rewarding effects of pain relief early in the course of rehabilitation
(e.g., via non-invasive brain stimulation, endogenous reward system training) and promote better
long-term adherence to rehabilitation interventions.
5. Conclusions
Treatment strategies for OA pain should be broadened beyond a simple focus on the affected joint(s).
While joint directed treatments remain sensible, it is important to screen for, recognize, and appropriately
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manage other factors (e.g., central sensitization, psychosocial factors, sleep problems) that may be
contributing to an individual’s pain experience. Rehabilitation is considered first line treatment
for OA pain. Core interventions that are widely recommended by evidence-based OA treatment
guidelines include regular aerobic and resistance exercise, self-management programs, and, where
appropriate, weight loss. A range of other options, such as manual therapy, thermal modalities,
TENS, and joint braces/splints, may also be useful adjunct therapies, although there is currently less
evidence supporting their use. CBT is increasingly recognized as a valuable treatment option for
selected individuals and may have important clinical benefits for psychological and sleep related
comorbidities. While further evidence is needed to support their clinical utility, novel treatment
approaches, such as pain neuroscience education, the use of disinhibitory interventions to augment
resistance training, blood flow restriction training, and brain directed treatments (e.g., illusory resizing
and non-invasive brain stimulation) may play an important role in the future rehabilitation of OA pain.
In addition, key avenues for future research include the development of personalized rehabilitation
interventions and improved methods to both enhance treatment adherence and better understand its
physiological underpinnings.
Author Contributions: Conceptualization: D.R. and E.H.; Literature search and data extraction: all authors;
Writing, original draft preparation: all authors; Writing, review & editing: all authors; Supervision: D.R.
Funding: This research received no external funding.
Acknowledgments: Eva Huysmans is a PhD research fellow of the Research Foundation Flanders (FWO
- 1108619N).
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125
Journal of
Clinical Medicine
Article
Early Changes in Pain Acceptance Predict Pain
Outcomes in Interdisciplinary Treatment for
Chronic Pain
Thomas Probst 1, *, Robert Jank 1 , Nele Dreyer 2 , Stefanie Seel 2 , Ruth Wagner 3 , Klaus Hanshans 3 ,
Renate Reyersbach 3 , Andreas Mühlberger 2 , Claas Lahmann 4 and Christoph Pieh 1
1 Department for Psychotherapy and Biopsychosocial Health, Danube University Krems, 3500 Krems, Austria
2 Institute for Psychology, Regensburg University, 93053 Regensburg, Germany
3 Hospital Barmherzige Brüder, 93049 Regensburg, Germany
4 Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Freiburg,
Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
* Correspondence: thomas.probst@donau-uni.ac.at
Received: 19 August 2019; Accepted: 26 August 2019; Published: 2 September 2019
Abstract: Studies have shown that pain acceptance is associated with a better pain outcome. The
current study explored whether changes in pain acceptance in the very early treatment phase of
an interdisciplinary cognitive-behavioral therapy (CBT)-based treatment program for chronic pain
predict pain outcomes. A total of 69 patients with chronic, non-malignant pain (at least 6 months)
were treated in a day-clinic for four-weeks. Pain acceptance was measured with the Chronic Pain
Acceptance Questionnaire (CPAQ), pain outcomes included pain intensity (Numeric Rating Scale,
NRS) as well as affective and sensory pain perception (Pain Perception Scale, SES-A and SES-S).
Regression analyses controlling for the pre-treatment values of the pain outcomes, age, and gender
were performed. Early changes in pain acceptance predicted pain intensity at post-treatment measured
with the NRS (B = −0.04 (SE = 0.02); T = −2.28; p = 0.026), affective pain perception at post-treatment
assessed with the SES-A (B = −0.26 (SE = 0.10); T = −2.79; p = 0.007), and sensory pain perception at
post-treatment measured with the SES-S (B = −0.19 (SE = 0.08); T = −2.44; p = 0.017). Yet, a binary
logistic regression analysis revealed that early changes in pain acceptance did not predict clinically
relevant pre-post changes in pain intensity (at least 2 points on the NRS). Early changes in pain
acceptance were associated with pain outcomes, however, the impact was beneath the threshold
defined as clinically relevant.
Keywords: chronic pain; pain acceptance; early change; interdisciplinary pain treatment
1. Introduction
Chronic pain (CP) is a serious clinical problem [1]. In the United States, more than 100 million
people suffer from CP and the annual costs for the society range between $560 and $635 billion [2]. As
the presence of pain affects all aspects of an individual’s functioning, an interdisciplinary approach
incorporating the knowledge and skills of different healthcare providers is essential [3].
Interdisciplinary treatments for CP are based on the bio-psycho-social model of pain [4]. Such
interdisciplinary treatments are conducted by a multi-professional team and address biological factors
(e.g., medication, exercise), psychological factors (e.g., cognitions, emotions), as well as social factors
(e.g., family, work) [4]. Several studies on CP showed that such interdisciplinary interventions are
efficacious in randomized controlled trials [5,6] as well as effective under the conditions of routine
care [7,8].
Psychotherapy is a central component in interdisciplinary pain treatments and cognitive-behavioral
therapy (CBT) is the most often used [9]. Several meta-analyses and reviews have evaluated the efficacy

J. Clin. Med. 2019, 8, 1373
of CBT for patients with CP [10]. A Cochrane review [11] revealed that CBT had statistically significant
but small effects on pain and disability. The effects on mood and catastrophizing were moderate. These
effects were compared with treatment-as-usual and wait-list control conditions. An integrative review
of Knoerl et al. reported that CBT reduced pain intensity in 43% of the trials [12].
Another psychotherapeutic approach for the treatment of CP is Acceptance and Commitment
Therapy (ACT; [13]). Acceptance and Commitment Therapy is a contextual form of CBT. Recent
reviews reported that ACT is beneficial for patients with CP [14,15]. The ACT aims at increasing
psychological flexibility (PF) and decreasing its counterpart psychological inflexibility [13,16]. While
psychological inflexibility is associated with psychological problems or even psychiatric symptoms,
PF is defined as the capacity to be in conscious and open contact with one’s thoughts and feelings,
and to behave according to one’s values and goals [17]. Psychological flexibility consists of six core
components (acceptance, cognitive defusion, self as a context, committed action, values, contact with
the present moment) [18]. In the context of CP, pain acceptance is central to PF. Pain acceptance refers
to the degree to which a patient is willing to live with pain or decides to get on with life despite pain.
The Chronic Pain Acceptance Questionnaire (CPAQ; [19]) is a psychometrically sound instrument to
operationalize pain acceptance and consists of a total scale and the following two subscales: Activity
engagement and pain willingness. Activity engagement refers to the performance of personally
valued activities, even in the presence of pain. Pain willingness refers to the willingness to give up
attempts to control or avoid pain. Several studies on ACT for CP found that improvements in pain
acceptance are associated with better pain outcomes [20–22]. Yet, two other studies suggest that
pain acceptance is a change mechanism in other treatments as well and no ACT specific treatment
process. These studies investigated whether improvements in pain acceptance are correlated with
pain outcomes in interdisciplinary CBT-based treatments. Baranoff et al. [23] reported that pre-post
improvements in pain acceptance were associated with improvements in almost all outcomes at the end
of an interdisciplinary CBT-based treatment for CP. In another study on interdisciplinary CBT-based
treatment for CP, Akerblom et al. [9] found that pain acceptance was not related to the outcome pain
intensity but that it was the strongest mediator for the other outcome measures. These studies showed
that improvements in pain acceptance play a crucial role for pain outcomes in different therapeutic
approaches for CP. Baranoff et al. as well as Akerblom et al. assessed pain acceptance at pre-treatment,
post-treatment, and at follow-up, but not during the interdisciplinary CBT-based treatment. To extend
these previous findings, pain acceptance was monitored during interdisciplinary CBT-based treatment
for CP in this project. The aim of the current study was to evaluate whether changes of pain acceptance
in the very early treatment phase (first week) predict pain outcomes at post-treatment. We hypothesized
that such early changes related to PF are predictors of pain outcomes at post-treatment, since early
changes of variables related to psychological inflexibility (e.g., catastrophizing, depression, anxiety)
have already been shown to be predictors of changes in pain and interference [24–27].
2. Materials and Method
2.1. Measurements
2.1.1. Pain Acceptance

Pain acceptance was measured with the Chronic Pain Acceptance Questionnaire (CPAQ [19,28]).
The CPAQ consists of 20 items and has satisfactorily psychometric properties [19,28,29]. For the present
study, only the total score of the CPAQ was analyzed. In the sample of the current study, the internal
consistency at pre-treatment was Cronbachs Alpha α = 0.87. Higher CPAQ scores indicate higher pain
acceptance. Early changes in pain acceptance were operationalized as the difference between the CPAQ
scores after the first treatment week and the CPAQ scores at the beginning of treatment. Differences
were calculated so that more positive differences indicate more improvements in pain acceptance.
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J. Clin. Med. 2019, 8, 1373
2.1.2. Pain Outcomes

Pain was measured with (1) an 11-point Numerical Rating Scale (NRS) and (2) the Pain Perception
Scale. The NRS is a common self-rating instrument to measure pain intensity in patients with CP
from 0 (no pain) to 10 (worst imaginable pain). The psychometric properties of the NRS have been
investigated in several studies [30,31]. In the current study, self-ratings on average pain intensity were
investigated. The Pain Perception Scale (SES) has 28 items and measures affective and sensory pain
perception [32]. Both scales showed good internal consistencies in our sample at pre-treatment, with
Cronbachs Alpha α = 0.93 for the affective pain perception scale (SES-A) and Cronbachs α = 0.88 for
the sensory pain perception scale (SES-S). The pre-treatment and post-treatment scores of the NRS and
SES were analyzed in the current study.
2.2. Study Sample

All patients taking part in the interdisciplinary CBT-based treatment for CP at the Hospital
Barmherzige Brüder, Regensburg (Germany) between June 2014 and November 2015 were asked to
participate in the study. During this time interval, N = 69 patients with CP were treated in a day-clinic
setting for four weeks and all of them gave written informed consent to partake in this study. All
patients suffered from chronic, non-malignant pain according to the ICD-10 diagnosis “chronic pain
disorder with somatic and psychological factors (F45.41)”. Of the patients, 36.2% had a comorbid
depression diagnosis, 50.7% fulfilled the criteria for at least one comorbid psychiatric disorder.
2.3. Intervention
The interdisciplinary treatment was performed according to the pain treatment program
“Marburger Schmerzbewältigungsprogramm” [33]. It is a CBT-based program for CP. The patients
received treatment for four weeks. Each week treatment lasted from 8:00 a.m. to 4:00 p.m. between
Monday and Thursday as well as from 08:00 a.m. to 01:15 p.m. at Friday. The treatment consisted
of individual treatment as well as group therapy (closed groups; up to 8 patients per group). The
interdisciplinary pain treatment was performed by a team of physicians, psychologists, physical
therapists, occupational therapists, and social workers. The CBT component focused mainly on
psychoeducation, the bio-psycho-social pain model, relaxation training, and directing the attention
towards positive experiences in group sessions and individual sessions. The CBT-based group sessions
took part four times per week, and the individual sessions once a week.
2.4. Statistical Analysis

All analyses were conducted with SPSS25. To evaluate pre-post changes of pain outcomes (NRS;
SES-A; SES-S), we conducted paired t-tests and calculated effect sizes (d) according to the following
formula: (Mprä − Mpost )/SDprä . Effect sizes are interpreted as follows: d ≥ 0.20 small effect, d ≥ 0.50
medium effect, d ≥ 0.80 large effect. Linear regression analyses (method selection “enter”) were
performed to address the research question whether early changes in pain acceptance predict pain
outcomes at post-treatment. One linear regression model was performed for each pain outcome, i.e.,
either the NRS at post-treatment, or the SES-A at post-treatment, or the SES-S at post-treatment were
the dependent variable. As predictors, we added early changes in pain acceptance, the pre-treatment
scores of the respective pain outcome variable (to control for pre-treatment values), age, and gender.
Moreover, a logistic regression analysis (method selection “enter”) was performed to evaluate whether
early changes in pain acceptance during the first treatment week predict clinically relevant changes
in pain intensity from pre- to post-treatment (≥2 points improvement on the NRS from pre- to
post-treatment) [34]. The dichotomized NRS (0 = pre-post NRS improvement < 2 points; 1 = pre-post
NRS improvement ≥2 points) was the dependent variable, and predictors were early changes in pain
acceptance, age, and gender. We included age and gender in the regression models, since they have
been shown to influence pain outcomes in previous studies [35,36]. Moreover, Pearson correlation
129
J. Clin. Med. 2019, 8, 1373
coefficients were calculated between the measures at pre-treatment to investigate potential overlap
between the measures. The significance level was set at p < 0.05 and the statistical tests were performed
two-tailed. Missing data were replaced by the average of the time series.
2.5. Ethical Consideration

The Ethics Committee of the University Clinic Regensburg approved the materials and methods
for this study. All patients gave written informed consent.
3. Results
The sample comprised N = 69 patients with CP (49 females), who were on average M = 52.62
(standard deviation (SD) = 9.78) years old. The participants gave written informed consent to participate
in the study, but during the study, some patients did not fill in the measures or dropped out from
treatment. Table 1 shows how many patients filled in the applied measures.
Table 1. Number of patients filling in the questionnaires. N = 69.
Number of Patients Filling in the Measure

Measure
N (%)
NRS pre-treatment 66 (96%)
NRS post-treatment 53 (77%)
SES-A pre-treatment 61 (88%)
SES-A post-treatment 52 (75%)
SES-S pre-treatment 62 (90%)
SES-S post-treatment 50 (72%)
CPAQ pre-treatment 52 (75%)
CPAQ after first treatment week 61 (88%)
Note: NRS = Numeric Rating Scale; SES-A = Affective Pain Perception Scale; SES-S = Sensory Pain Perception Scale;
CPAQ = Chronic Pain Acceptance Questionnaire.
The correlations between the measures at pre-treatment are presented in Table 2. Pain intensity
was positively correlated with affective pain perception (r = 0.56; p < 0.001) and with sensory pain
perception (r = 0.25; p = 0.040). Affective and sensory pain perception were also positively correlated
(r = 0.57; p < 0.001). Significantly negative correlations emerged between pain intensity and pain
acceptance (r = −0.27; p = 0.025) as well as between affective pain perception and pain acceptance
(r = −0.48; p < 0.001).
Table 2. Correlations between the measures at pre-treatment. N = 69.
SES-A SES-S CPAQ

NRS r 0.56 0.25 −0.27
p-value <0.001 0.040 0.025
SES-A r 0.57 −0.48
p-value <0.001 <0.001
SES-S r −0.23
p-value 0.061
Note: NRS = Numeric Rating Scale; SES-A = Affective Pain Perception Scale; SES-S = Sensory Pain Perception Scale.
Results of the analyses evaluating pre-post changes of the pain outcomes are presented in Table 3.
Pain intensity improved (t(68) = 5.82; p < 0.001) with a large effect size of d = 0.81, affective pain
perception improved (t(68) = 4.43; p < 0.001) with a medium effect size of d = 0.60, and sensory pain
perception improved (t(68) = 3.26; p = 0.002) with a small effect size of d = 0.41.
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J. Clin. Med. 2019, 8, 1373
Table 3. Pre–post changes in pain outcomes. N = 69.
Pre-Treatment Post-Treatment
Statistics Effect Size
M (SD) M (SD)
Pain intensity (NRS) 6.33 (1.62) 4.97 (1.65) t(68) = 5.82; p < 0.001 d = 0.84
Affective Pain Perception (SES-A) 35.90 (9.60) 30.12 (10.21) t(68) = 4.43; p < 0.001 d = 0.60
Sensory Pain Perception (SES-S) 31.94 (8.64) 28.38 (8.02) t(68) = 3.26; p = 0.002 d = 0.41
SD = standard deviation.
Three linear regression analysis were conducted to evaluate if early changes in pain acceptance
predict the pain outcomes (NRS, SES-A, SES-S) at post-treatment. As can be seen in Table 4, early
changes in pain acceptance were negatively correlated with the three pain outcomes. This means that
early improvements in pain acceptance were associated with more favorable pain outcomes (i.e., less
pain intensity, less affective pain perception, and less sensory pain perception at post-treatment), since
higher values on the NRS, SES-A, and SES-S indicate more severe pain, whereas more positive CPAQ
difference scores indicate larger early improvements in pain acceptance.
Table 4. Results of the multiple regression analyses testing early changes in pain acceptance as
predictors of pain outcomes. N = 69.
Unstandardized Standardized
Coefficients Coefficients
B (SE) Beta T p-Value
Pain intensity (NRS)
(Constant) 3.31 (1.21) 2.74 0.008
Early changes in pain acceptance (CPAQ) −0.04 (0.02) −0.27 −2.28 0.026
NRS pre-treatment 0.34 (0.12) 0.33 2.81 0.007
Age −0.01 (0.02) −0.06 −0.46 0.648
Gender 0.07 (0.43) 0.02 0.17 0.869
Affective Pain Perception (SES-A)
(Constant) 22.45 (7.03) 3.20 0.002
SES-A pre-treatment 0.41 (0.11) 0.38 3.66 0.001
Age −0.17 (0.11) −0.16 −1.48 0.145
Gender 1.74 (2.43) 0.08 0.72 0.476
Sensory Pain Perception (SES-S)
(Constant) 23.53 (6.21) 3.79 <0.001
SES-S pre-treatment 0.35 (0.10) 0.38 3.50 0.001
Age −0.10 (0.09) −0.12 −1.10 0.276
Gender −0.53 (1.95) −0.03 −0.27 0.787
CPAQ = Chronic Pain Acceptance Questionnaire; SE = standard error.
Outcome pain intensity (NRS): R2 was 0.17 (F(4, 64) = 3.34, p = 0.015). Early changes in pain
acceptance predicted pain intensity at post-treatment (B = −0.04 (standard error (SE) = 0.02); T = −2.28;
p = 0.026) when statistically controlling for pain intensity at pre-treatment (B = 0.34 (SE = 0.12); T = 2.81;
p = 0.007), age (B = −0.01 (SE = 0.02); T = −0.46; p = 0.648), and gender (B = 0.07 (SE = 0.43); T = 0.17;
p = 0.869).
Outcome affective pain perception (SES-A): R2 reached 0.31 (F(4, 64) = 7.27, p < 0.001). Affective
pain perception at post-treatment was predicted by early changes in pain acceptance (B = −0.26
(SE = 0.10); T = −2.79; p = 0.007) when statistically controlling for affective pain perception at
pre-treatment (B = 0.41 (SE = 0.11); T = 3.66; p = 0.001), age (B = −0.17 (SE = 0.11); T = −1.48; p = 0.145),
and gender (B = 1.74 (SE = 2.43); T = 0.72; p = 0.476).
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J. Clin. Med. 2019, 8, 1373
Outcome sensory pain perception (SES-S): R2 amounted to 0.27 (F(4, 64) = 5.91, p < 0.001). When
statistically controlling for sensory pain perception at pre-treatment (B = 0.35 (SE = 0.10); T = 3.50;
p = 0.001), age (B = −0.10 (SE = 0.09); T = −1.10; p = 0.276), and gender (B = −0.53 (SE = 1.95); T = −0.27;
p = 0.787), sensory pain perception at post-treatment was predicted by early changes in pain acceptance
(B = −0.19 (SE = 0.08); T = −2.44; p = 0.017).
For the outcome pain intensity, we calculated how many patients show a clinically relevant
improvement from pre- to post-treatment of at least 2 points on the NRS [34]. N = 31 (45%) improved
at least 2 points from pre- to post-treatment and N = 38 (55%) did not. A logistic regression analysis
was performed to investigate whether early changes in pain acceptance predict clinically relevant
pre-post changes in pain intensity. The results of this logistic regression (−2 Log-Likelihood = 90.77;
Cox and Snell R-Quadrat = 0.06; Nagelkerkes R-Quadrat = 0.08) showed that early changes in pain
acceptance do not predict clinically significant NRS changes (Exp(B) = 1.04; 95% confidence interval
(CI): 0.99; 1.09; p = 0.157) when controlling for age (Exp(B) = 1.03; 95% CI: 0.98; 1.09; p = 0.304) and
gender (Exp(B) = 1.07; 95% CI: 0.36; 3.25; p = 0.900).
4. Discussion
This study evaluated whether early changes in pain acceptance predict pain outcomes at the end
of an interdisciplinary CBT-based treatment for CP. As pain outcomes, we evaluated pain intensity,
affective pain perception, and sensory pain perception. The results showed that early changes in pain
acceptance within the first treatment week were associated with less pain intensity, less affective pain
perception, and less sensory pain perception at the end of an interdisciplinary pain program. However,
clinically relevant changes in pain intensity from pre- to post-treatment were not predicted by early
changes in pain acceptance.
Our results extend past research on pain acceptance in interdisciplinary CBT-based treatments
for CP [9,23], which showed that changes in pain acceptance are associated with outcomes. Yet, the
previous studies did not investigate pain acceptance in the early treatment phase. With regard to
the pain outcome pain intensity, our results appear to be in contrast to another study [9] where the
outcome pain intensity was not correlated with changes in pain acceptance. One explanation could be
that Akerblom et al. [9] analyzed pre-post changes in pain acceptance, whereas we investigated early
changes in pain acceptance during the first treatment week. It might be that the outcome pain intensity
is predicted by early changes in pain acceptance but not by pre-post changes in pain acceptance. This
speculation receives some support from pain studies showing that different predictors of the outcome
can be found in the early and late treatment phase [24–27].
When interpreting our results, it should be kept in mind that pain acceptance is no explicit
treatment target in CBT-based treatments. We can only speculate about the factors influencing early
changes in pain acceptance. Possibly, non-specific common factors like the therapeutic alliance or
hope might be associated with early changes in pain acceptance as these common factors have been
discussed to play a role in the early phase of psychotherapy [37,38], but this needs to be further studied
in the area of pain. It should also be kept in mind that some of the pain outcome measures (NRS,
SES-A) were significantly correlated with the pain acceptance measure at pre-treatment. Therefore,
the correlation between changes in pain acceptance and changes in pain intensity as well as changes
in affective pain perception may be overstated. There are several further shortcomings to discuss.
Although the external validity/generalizability of the results is positively influenced by the conditions
of routine practice, the following points limit the generalizability. All patients had the ICD-10 diagnosis
“chronic pain disorder with somatic and psychological factors (F45.41)” and it remains unclear how
early changes in pain acceptance influence pain outcomes in patients with other forms of pain. The
representativeness is further reduced by the rather small sample size (N = 69) as well as the relatively
large amount of missing data. The sample is, for example, too small for a sound investigation of
moderators between early changes in pain acceptance and pain outcomes. Future larger studies could
include age and gender as moderators and investigate whether the effect of early changes in pain
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J. Clin. Med. 2019, 8, 1373
acceptance on pain outcomes interacts with age and gender. Besides CP, more than half of the patients
had various, especially psychiatric diagnoses. Another limitation is that the diagnoses were made by
the clinic team, but not with a structured or standardized clinical interview. Due to the naturalistic
design we did not calculate a power analysis ahead of the study. We replaced missing data by the
average of the time series. This approach leads to an overestimation of the effect compared to replacing
missing post-treatment data with the pre-treatment values. Other strategies to handle missing data
(e.g., Expectation-Maximization algorithm) might lead to different results. Furthermore, regression
analysis does not allow drawing causal inferences and the internal validity of the results is rather
low. A randomized controlled trial comparing a condition including a component to increase pain
acceptance in the early treatment phase and a condition excluding this component would produce
results of higher internal validity. Based on our results, one would expect that pain outcomes are
better in the condition with the component to increase pain acceptance in the early treatment phase.
A further limitation is that we only included pain acceptance as process variable. The inclusion of
more process variables (e.g., pain catastrophizing) would have allowed to investigate whether early
changes in one process variable are more or less important predictors of pain outcomes than early
changes in other process variables. Another shortcoming is that pain intensity and pain perception
were the solely outcomes in the current study and other outcomes such as functioning or patient
satisfaction should also be integrated to evaluate treatments for CP [39]. Pain acceptance might
also be an important outcome in treatments for CP and we analyzed pain acceptance as a process
measure only. Furthermore, our results rely on self-report data and complementary assessments of
more objective pain outcomes (e.g., quantitative sensory testing) would be welcome in future studies.
Moreover, our definition of early change should be discussed in more detail. We investigated difference
scores within the first week to investigate early changes in pain acceptance. The first treatment week
might a suitable time frame to study early changes, but other studies defined the change from pre- to
mid-treatment [25,26], or the change from pre-treatment to the third treatment week [24,40] as early
change. It should also be mentioned that there are several other approaches to operationalize change
rate [41] such as deviations from expected recovery curves [40], sudden gains [42] reliable change [43]
or the method of percent of improvement [44]. Finally, we only investigated how early changes in pain
acceptance influence the short-term outcome at the end of the interdisciplinary treatment for CP, but
we do not know how the long-term outcome is predicted by early changes of pain acceptance due to
the lack of follow-up assessments.
5. Conclusions
Early changes in pain acceptance are associated with continuous pain outcomes, but not with
clinically relevant improvements in pain intensity.
Author Contributions: Conceptualization, T.P. and A.M..; methodology, T.P.; software, T.P., R.J., N.D. and S.S.;
validation, A.M., C.L. and C.P.; formal analysis, T.P. and R.J.; investigation, N.D. and S.S.; resources, R.W., K.H.,
R.R., A.M. and C.P.; data curation, N.D. and S.S.; writing—original draft preparation, T.P. and R.J.; writing—review
and editing, T.P. and C.P.; visualization, T.P.; supervision, T.P., A.M., C.L. and C.P.; project administration, T.P.,
N.D., S.S., R.W., K.H., R.R. and A.M.
Funding: The research was performed as a part of the employment of the authors. Open Access Funding by the
University for Continuing Education Krems.
Acknowledgments: The data underlying the findings of the study are available from the corresponding author
upon request.
Conflicts of Interest: The authors declare that there is no conflict of interest regarding the publication of this paper.
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Journal of
Clinical Medicine
Article
Cost–Utility of Mindfulness-Based Stress Reduction
for Fibromyalgia versus a Multicomponent
Intervention and Usual Care: A 12-Month
Randomized Controlled Trial (EUDAIMON Study)
Adrián Pérez-Aranda 1,2,3,4 , Francesco D’Amico 5 , Albert Feliu-Soler 1,2,3, *, Lance M. McCracken 6 ,
María T. Peñarrubia-María 7,8,9 , Laura Andrés-Rodríguez 1,2,3 , Natalia Angarita-Osorio 1,2 ,
Martin Knapp 5,8 , Javier García-Campayo 3,10 and Juan V. Luciano 1,2,3, *
1 Group of Psychological Research in Fibromyalgia & Chronic Pain (AGORA), Institut de Recerca Sant Joan de
Déu, 08950 Esplugues de Llobregat, Spain
2 Teaching, Research & Innovation Unit, Parc Sanitari Sant Joan de Déu, 08830 Sant Boi de Llobregat, Spain
3 Primary Care Prevention and Health Promotion Research Network, RedIAPP, 28029 Madrid, Spain
4 Department of Clinical Psychology and Psychobiology (Section Personality, Assessment and Psychological
Treatments), University of Barcelona, 08193 Barcelona, Spain
5 The London School of Economics and Political Science (LSE), London WC2A 2AE, UK
6 Department of Psychology, Uppsala University, SE-751 05 Uppsala, Sweden
7 Primary Health Centre Bartomeu Fabrés Anglada, SAP Delta Llobregat, Unitat Docent Costa de Ponent,
Institut Català de la Salut, 08850 Gavà, Spain
8 Centre for Biomedical Research in Epidemiology and Public Health, CIBERESP, 28029 Madrid, Spain
9 Fundació IDIAP Jordi Gol I Gurina, 08007 Barcelona, Spain
10 Department of Psychiatry, Miguel Servet Hospital, Aragon Institute of Health Sciences (I+CS),
50009 Zaragoza, Spain
* Correspondence: a.feliu@pssjd.org (A.F.-S.); jvluciano@pssjd.org (J.V.L.);
Tel.: +34-93-640-6350 (ext. 1-2540) (J.V.L.)
Abstract: Fibromyalgia (FM) is a prevalent, chronic, disabling, pain syndrome that implies high
healthcare costs. Economic evaluations of potentially effective treatments for FM are needed. The aim
of this study was to analyze the cost–utility of Mindfulness-Based Stress Reduction (MBSR) as an
add-on to treatment-as-usual (TAU) for patients with FM compared to an adjuvant multicomponent
intervention (“FibroQoL”) and to TAU. We performed an economic evaluation alongside a 12 month,
randomized, controlled trial; data from 204 (68 per study arm) of the 225 patients (90.1%) were
included in the cost–utility analyses, which were conducted both under the government and the
public healthcare system perspectives. The main outcome measures were the EuroQol (EQ-5D-5L)
for assessing Quality-Adjusted Life Years (QALYs) and improvements in health-related quality of life,
and the Client Service Receipt Inventory (CSRI) for estimating direct and indirect costs. Incremental
cost-effectiveness ratios (ICERs) were also calculated. Two sensitivity analyses (intention-to-treat,
ITT, and per protocol, PPA) were conducted. The results indicated that MBSR achieved a significant
reduction in costs compared to the other study arms (p < 0.05 in the completers sample), especially in
terms of indirect costs and primary healthcare services. It also produced a significant incremental
effect compared to TAU in the ITT sample (ΔQALYs = 0.053, p < 0.05, where QALYs represents
quality-adjusted life years). Overall, our findings support the efficiency of MBSR over FibroQoL and
TAU specifically within a Spanish public healthcare context.
Keywords: fibromyalgia; cost–utility; cost-effectiveness; quality-adjusted life years

J. Clin. Med. 2019, 8, 1068
1. Introduction
Fibromyalgia (FM) is a disabling syndrome of unknown etiology mainly characterized by chronic
widespread musculoskeletal pain, fatigue, stiffness, sleep problems, perceived cognitive dysfunction,
and mood disturbances [1]. It is usually diagnosed in women aged between 30 and 50 years old and
has an estimated prevalence of around 2% in the general population [2,3]. Health-related quality of life
is significantly lower for people with FM compared to the general population and similar or lower than
those seen for other medical conditions such as osteoarthritis, rheumatoid arthritis, or osteoporosis [4].
FM is a costly syndrome for both healthcare funders and society in general. It is the chronic pain
condition with the highest rates of unemployment, sick-leave, claims for incapacity benefits, work
absenteeism, and per-patient costs [5]. FM patients’ direct costs have been described as three times
higher than those for patients with other pathologies but similar sociodemographic characteristics [6].
Regarding indirect costs, the range of women with FM who are able to preserve their jobs has been
reported to be between 34% and 77% [7,8], and reducing work hours due to the impact of symptoms
is a common practice among patients with FM [9]. Altogether, FM is second only to irritable bowel
syndrome in its contribution to the approximately $300B in costs that inflammatory diseases and
related chronic syndromes are expected to generate in the US in coming years [10]. There is a need,
therefore, to optimize the development and the implementation of treatments for FM that, next to
early accurate diagnoses and methods to support treatment-adherence, would help to address this
burden [10].
To date, no cure has been found for FM, although different pharmacological (pregabalin
and noradrenaline reuptake inhibitors) and non-pharmacological interventions (aerobic exercise,
cognitive-behavioral therapy (CBT), multicomponent therapy, and “third-wave” CBT such as
mindfulness-based interventions (MBIs) or Acceptance and Commitment Therapy (ACT)) have
demonstrated some benefits for reducing the impact of the symptoms and increasing quality of
life [11,12]. The pharmacological approach is most common for FM despite its limited effectiveness.
In fact, non-pharmacological treatments appear to show effects in more separate symptom domains as
compared with pharmacological treatments for FM [13].
A crucial aspect for including interventions such as those mentioned above in any health
system is the balance between costs and benefits that each intervention produces. Policy-makers are
faced with limited economic resources and therefore must prioritize among available alternatives.
Cost-effectiveness analyses allow cost comparisons of different treatments in relation to the health
improvement that each one produces [14]. The cost–utility analysis is a type of cost-effectiveness analysis
that allows comparison of therapies across different pathologies, as it is based on quality-adjusted life
years (QALYs), a measure that combines the length of survival and its quality, regardless of the illness.
The value of a QALY ranges from 0 (death) to 1 (best imaginable health), although states deemed worse
than death can have negative values. Thus, cost–utility is measured in costs per QALYs.
Unfortunately, to date, there have been few cost-effectiveness or cost–utility studies of effective
interventions for FM, although interest in these has recently increased. To our knowledge, 12 studies
have assessed the cost–utility of different treatments for FM [14–25]. Four of them focused on
pharmacological treatments, concluding that both pregabalin [15,18,19] and duloxetine [20] would be
cost-effective compared to other pharmacological options or placebo. Regarding non-pharmacological
interventions, one study evaluated the cost–utility of a cognitive-educational treatment for FM and
found that the group discussion component alone was more cost-effective as compared to adding a
cognitive component [21]. However, further studies have found cognitive-behavioral interventions
to be cost-effective. This includes Schröder et al. [25], who studied the long-term cost–utility of a
CBT group compared to usual care in functional somatic syndromes such as FM and found that the
intervention improved quality of life and reduced costs in the long term.
In another study, Luciano et al. [22] found that the multicomponent intervention FibroQoL,
consisting of the combination of psychoeducation and training in relaxation, was cost-effective in the
long-term compared to usual care. The same research group found that CBT was more cost-effective
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J. Clin. Med. 2019, 8, 1068
than recommended pharmacological treatment (RPT) and usual care due to significant reduction in
direct costs, although it was not associated with significantly improved quality of life [23]. More
recently, the same authors compared group ACT (GACT) to RPT and a waitlist control (WLC),
and the cost–utility analysis favored GACT in comparison to RPT and WLC [14]. Even more recently,
Hedman-Lagerlöf et al. [24] evaluated the cost-effectiveness of an internet-based exposure intervention
for FM (to stimuli that elicit pain-related distress) compared to WLC and found that the intervention
could be highly cost-effective, as each incremental responder generated an annual societal cost reduction
of more than $15,000.
Certainly, some treatments show limited cost-effectiveness. For example, in studies of alternative
treatments including aquatic training [17] and spa treatments [16], the first concluded that an eight
month aquatic training was cost-effective compared to usual care, although some external variables
(e.g., distance from the patients’ homes or number of patients that participate in each session) could
have a major impact on the cost of the intervention. The second found that the spa treatment improved
the quality of life only temporarily but not in the long term and resulted in neither a significant decrease
of health care consumption nor in productivity loss.
Regarding MBIs, economic evaluations are scarce and have been specially focused on depression
and emotional unstable personality disorder [26] but not on FM. Economic evaluation of MBIs for FM
seems particularly relevant because these interventions have demonstrated promising clinical results
in previous studies [27–30], albeit with some methodological limitations, such as small sample sizes or
lack of long-term follow-up assessments.
As a response to limitations of previous studies, the EUDAIMON study conducted in Spain
recruited a large sample of patients with FM (N = 225) and employed a 12 month follow-up evaluation.
Results showed superior efficacy of Mindfulness-Based Stress Reduction (MBSR) compared to the
multicomponent intervention FibroQoL and to usual care [31]. MBSR led to improved functional
impairment, FM-related symptoms, and other secondary outcomes (e.g., depressive and anxiety
symptoms, perceived stress, pain catastrophizing, cognitive dysfunction) with moderate to large effect
sizes at post-treatment assessment. Some of these improvements were partially lost in the long-term,
probably due to reduced, intermittent, and non-structured practice of mindfulness once the eight week
intervention finished.
The present study extends our earlier work on clinical efficacy of MBSR in patients with FM [31]
and shows the results of an economic evaluation alongside the randomized controlled trial (RCT).
Here, we compare for the first time the 12 month health care and societal costs as well as the 12 month
cost–utility of MBSR compared to FibroQoL and usual care (passive control arm) in terms of QALY
gains and increases in health-related quality of life in Spanish patients with FM.
2. Methods
2.1. Participants
Following a multi-stage recruitment process, a total of 225 adult patients diagnosed with FM
according to the American College of Rheumatology (ACR) 1990 criteria [32] were recruited from the
Rheumatology Service at Sant Joan de Déu Hospital (St. Boi de Llobregat, Spain) and participated in
the EUDAIMON study between January 2016 and April 2018. As seen in Figure 1, the total sample was
randomized into three study arms, as explained below. However, due to missing data in some of the
baseline variables needed for the cost–utility analyses (i.e., EQ-5D VAS and/or FM-related medication
costs), 21 patients were not included in the economic evaluation, and the final sample of this study
consisted of 204 individuals with FM (68 per study arm).
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Figure 1. Trial flow chart describing the recruitment process of all three study arms. Note: MBSR =
Mindfulness-Based Stress Reduction; TAU = Treatment-as-usual; ITT = intention-to-treat; PPA = Per
protocol analysis.
2.2. Inclusion and Exclusion Criteria

All 567 potential participants underwent a phone screening to assess the following inclusion
criteria: (1) aged between 18–65 years old; (2) able to understand Spanish language; and (3) provided
informed consent to participate, and exclusion criteria: (1) participation in a concurrent treatment trial;
(2) presence of cognitive impairment according to the Mini Mental State Examination (score < 27) [33];
(3) participation in psychological treatment during the last 12 months; (4) previous experience in
meditation or other mind-body therapies; (5) presence of comorbid severe mental or medical disorders
that could interfere with treatment; (6) pregnancy; and (7) involvement in ongoing litigation relating
to FM.
Those participants meeting the eligibility criteria were scheduled for a first face-to-face
interview in the hospital with a trained clinical psychologist blind to treatment allocation where
inclusion criteria were checked again; if the criteria were fulfilled, the baseline evaluation started.
The evaluations consisted of the administration of a battery of measures to assess different clinical
outcomes (e.g., functional impairment, “fibromyalginess”, anxiety and depression symptoms, pain
catastrophizing, cognitive dysfunction, and perceived stress), process variables (e.g., mindfulness
facets, self-compassion, and psychological inflexibility) and quality of life and cost-related outcomes
(e.g., use of clinical services, medication, sick leaves, etc.). Moreover, during the baseline clinical
interview, the Structured Clinical Interview for DSM-IV-Axis I Depressive disorders (SCID-I) was
used to establish the diagnostic of a current episode of major depression, a previous episode of major
depression, and/or dysthymia. See Pérez-Aranda et al. [31] for more detailed information.
2.3. Design
The study is registered at Clinicaltrials.gov under registration number NCT02561416. A 12 month
RCT was performed with random allocation of the participants to 3 arms (using a computer-generated
randomization list): MBSR added to treatment-as-usual (TAU); FibroQoL added to TAU; and TAU alone.
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A detailed description of the study protocol can be found elsewhere [34]. In summary, all recruited
patients signed an informed consent and participated voluntarily in the RCT. This included three
assessments: at baseline, post-treatment (or 2 months after baseline, in the case of the participants
allocated in the TAU condition), and at 12 months follow-up (48 weeks after randomization).
The study was approved by the Ethics Committee at the Sant Joan de Déu Foundation (PIC-102-15)
and was performed in accordance with the ethical standards laid down in the 1964 Declaration of
Helsinki and its following updates.
2.4. Interventions
2.4.1. MBSR
MBSR is a transdiagnostic program originally developed by Jon Kabat-Zinn [35] to help patients
with chronic conditions. Mindfulness is defined as “the awareness that emerges through paying
attention on purpose, in the present moment, and nonjudgmentally to the unfolding of experience” [36].
In MBSR, structured training in mindfulness is provided to help patients to relate to their physical
and psychological conditions in more accepting and non-judgmental ways [37]. We used the MBSR
protocol developed at the University of Massachusetts Medical School (USA) with minimal adaptations
for our patients with FM attending to the characteristics of this population. The program consisted of
eight weekly 2 h sessions and included the usual one half-day of silent retreat (6 h long session between
weeks 6 and 7), although it was optional in our study. The book Con rumbo propio [38] and audiotapes
were provided to facilitate practice at home, which is reinforced throughout the program and recorded
in a practice log. The intervention was delivered in a group format (approximately 15 patients per
group), and each group was conducted by a different properly trained MBSR instructor.
2.4.2. FibroQoL
The FibroQoL program is a multicomponent intervention developed by expert and
multidisciplinary groups in Catalonia between 2006 and 2007. It was used as an active treatment
comparator because it had previously demonstrated cost–utility compared to TAU for FM [22,39].
MBSR and FibroQoL were practically equivalent in terms of structure, which offers a comparison of
MBSR to an active control that matches MBSR in non-specific factors but does not contain mindfulness
techniques. FibroQoL consists of eight weekly 2 h sessions that are divided in two parts: four sessions
of psychoeducation in which patients receive updated information about pathophysiology, diagnosis,
and management of FM symptoms, and another four sessions of training in relaxation and self-hypnosis
through different techniques with goals to generate a state of deep relaxation, achieve control over the
body and pain, and imagine one’s life in the future without pain [12]. Audiotapes were provided to
facilitate practice at home. The recently published Beginner’s Guide to Fibromyalgia [40] was also
provided for giving updated information about FM syndrome. The intervention was delivered in
a group format (15 patients per group), and one team formed by two psychologists, three family
physicians, and a rheumatologist conducted the five groups.
2.4.3. TAU
Patients randomized to this arm received no additional active treatment over the study period but
continued with their regular pattern of medication (if any). The usual treatment of FM typically includes
analgesics, anxiolytics, opioids, antidepressants, and/or anti-inflammatories, and recommendations
for practicing aerobic exercise regularly. For ethical reasons, participants allocated to TAU arm were
offered participation in an MBI at the end of the study.
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2.5. Outcome Measures
2.5.1. The EuroQol Questionnaire [41]

The five-level version of the EuroQol five-dimensional classification system (EQ-5D-5L) is a widely
used health-related quality of life instrument with a non-disease-specific classification system that
consists of two parts.
In the first part, the patient chooses one of five levels of severity (1 = no problems, 2 = mild
problems, 3 = moderate problems, 4 = severe problems, 5 = extreme problems) in five domains:
mobility, self-care, usual activities, pain, and anxiety/depression. The time frame is the day of reporting.
The combination of the answers given to these domains results in 3125 (55 ) different health states.
The utility scores are obtained from the EQ-5D classification system and are used to rate patients’
health-related quality of life. This continuous variable includes negative values, which indicate a health
state “worse than death”, 0, which indicates a state “as bad as death”, and 1, which represents “perfect
health”. This scale reflects the health status as described by the subject and is often the preferred
method for economic evaluations from a general perspective. In order to derive the EQ-5D utility value
from a set of EQ-5D-5L domains, there exist different sets of country-specific preference weights; in our
case, these utility values were calculated using the Spanish tariffs of EQ-5D-5L [42], since they are more
relevant to our decision-making context. EQ-5D utility values are then used to estimate QALYs, which
represent a common measure to assess the outcomes associated with different treatments both in terms
of patients’ quality of life and survival [43]. In terms of QALYs, a year of perfect health is worth 1,
and a year of less than perfect health is worth less than 1.
The second part of the questionnaire is a visual analogue scale (EQ VAS) on which participants
record their current overall health status ranging from 0 (worst imaginable health) to 100 (best
imaginable health).
2.5.2. The Client Service Receipt Inventory (CSRI) Spanish Version

The Client Service Receipt Inventory (CSRI) [44] was used to collect retrospective data on
medication and service receipt. For medication intake, patients were asked to bring their daily
medication prescriptions and the following information for FM-related drugs (i.e., analgesics,
anti-inflammatories, opioids, antiepileptics, muscle relaxants, antidepressants, and anxiolytics) was
recorded: the name of the drug, the dosage, the total number of prescription days, and the daily dosage
consumed. Regarding service receipt, patients were asked about the total visits to emergency services,
the total days of general inpatient hospital admissions, the number of diagnostic tests administered,
and the total visits to general practitioner, nurse, social worker, psychologist, psychiatrist, group
psychotherapy, and other community health care professionals, specifying in each case if these services
were provided by the public or by the private sector. The CSRI was administered on two occasions:
at baseline and at 12 month follow-up, both referring to the previous 12 months.

The present economic evaluation is reported according to the Consolidated Health Economic
Evaluation Reporting Standards statement [45] (see Table S1) and follows the Good Research Practices
for Cost-Effectiveness Analysis Alongside Clinical Trials [46]. Statistical analyses were performed
using STATA v13.0 (StataCorp, College Station, TX, USA) and SPSS v22 (SPSS Inc., Chicago, IL, USA).
We estimated costs from the healthcare and the government perspectives, taking the previous
year as the time frame. Catalonia has full governance of health and social care and, as in every
other Spanish region, healthcare is universal and publicly financed. The government perspective
included direct healthcare costs assumed by the Catalan government (out-of-pocket costs and costs
associated with private insurances were not included) and indirect costs related to productivity losses
assumed by the Spanish government. The healthcare perspective included only direct healthcare costs.
These costs were calculated by summing costs from medications, use of healthcare services, medical
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tests, and costs of the professionals delivering the MBSR and FibroQoL treatments. We calculated the
cost of medications by consulting the price per milligram in the Vademecum International (Red Book;
edition 2016) and included the value-added tax. Thus, we computed total costs of medications by
multiplying the price per milligram by the total daily dose consumed (in milligrams) and the number of
days that the pharmacological treatment was delivered. The SOIKOS database of health care costs [47]
was the principal source of unit cost data for health services use and medical tests. The total cost
of the MBSR and the FibroQoL treatments took into account the price per patient per group session
for the health professional who provided the sessions. Attendance to MBSR and FibroQoL sessions
was obtained by consulting professionals’ records. The cost of treatment sessions and resources was
considered equal across all sessions and groups, but the number of participants attending those sessions
was not; therefore, MBSR and FibroQoL costs were dependent on the number of sessions attended
by participants.
We calculated indirect costs (lost productivity) from the human capital approach. We multiplied
the minimum daily wage in Spain for 2016 by the number of days on sick leave reported by each
patient. Finally, we calculated total costs by summing the direct and the indirect costs. Unit costs are
reported in Euros (€) based on 2016 prices. Table 1 displays the unit costs for the calculation of direct
and indirect costs. Given that the time horizon was the previous year, it was not necessary to apply a
discount to the costs.
Table 1. Unit costs used in the calculations of direct and indirect costs (Financial Year 2016; values in €).
Service (Unit) Costs (€)

Health care
General practitioner (per appointment) 36.97
Nurse/psychiatric nurse (per appointment) 34.13
Social worker (per appointment) 35.78
Clinical Psychologist (per appointment) 45.06
Psychiatrist (per appointment) 45.06
Other medical specialists (per appointment) 43.82
Accident & Emergency in hospital (per attendance) 99.34
Hospital stay (per night) 112
Diagnostic tests (range) 6.13–455.53
Pharmacological treatment (per daily dose) * Various
MBSR & FibroQoL (per participant per group session) 45.06
Productivity loss
Absenteeism from work (minimum daily wage) 21.8
Note: Unit costs were applied to each resource use to compute the total cost of resources used by each participant.
All unit costs were for the year 2016. * The cost of prescribed medications was calculated by determining the price
per milligram according to the Vademecum International (Red Book; edition 2016) and included the value-added tax.
The comparison between two intervention groups in the frame of an economic evaluation results
in four potential scenarios: (1) the intervention costs less and is more effective than the alternative;
(2) the intervention costs more and is less effective than the alternative; (3) the intervention costs
less but is less effective than the alternative; and (4) the intervention costs more but is more effective
than the alternative. The first two scenarios exhibit strong dominance; thus, the decision on which
intervention to adopt is normally straightforward. For the other two scenarios, the decision depends on
the incremental cost-effectiveness ratio (ICER), which is defined as the ratio between incremental costs
and incremental effects measured on QALYs or EQ VAS points [48]. For considering the intervention
cost-effective, each country establishes an investment ceiling, which in the case of Spain is €25,000 per
QALY [14].
Our cost-effectiveness analyses were implemented using the Zellner’s seemingly unrelated
regression (SUR) model [49]. Estimates were performed using STATA’s sureg command. Using the
SUR method for cost-effectiveness purposes implies the use of a bivariate system of regressions that
includes both costs and outcomes (with the latter being either QALYs or EQ VAS, depending on the
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model considered) as the dependent variables of the two separate equations, which are estimated
jointly. The regressions of costs and outcomes are therefore part of two regressions on treatment
allocation (i.e., whether they were assigned to MBSR, FibroQoL, or TAU) plus an additional set of
control variables (measured at baseline): age, gender, marital status, education level, employment
status, current episode of major depression, baseline costs, or baseline outcome, depending on the
equation considered. Estimates of incremental cost and of incremental effect values using the SUR
method described above were derived with 1000 bootstrap replications in order to address a possible
skewness in the distribution of the dependent variables [50].
We assessed cost-effectiveness of the interventions using several different scenarios. In the first
instance, we performed a complete case analysis (CCA), including only the 128 patients who were
assessed both at baseline and at 12 month follow-up. Additional scenarios (sensitivity analysis)
adopted instead intention-to-treat (ITT) and per protocol analysis (PPA) approaches. In order to be
able to perform an ITT analysis, we needed to impute missing values for those variables that were
missing at the 12 month follow-up. In order to do so, we used multiple imputation methods with the
chained equations approach [51]. Variables that presented most missing values were, in particular,
the EQ-5D-5L domains and the costs of the non-responders at 12 months follow-up. The imputation
model, run on ten imputed datasets, included all the main sociodemographic and prognostic variables
associated with the outcome variables and the other variables containing missing values. In the present
study, patients who had baseline CSRI data (n = 204) comprised the ITT sample—missing baseline
data were not imputed. Finally, the PPA scenario (2nd sensitivity analysis) was estimated on a sample
that included only those who attended at least 6 treatment sessions out of 8, with a final sample size of
107 patients.
3. Results
In terms of descriptive statistics, no significant differences were observed between the three
study arms in any outcome but the clinical diagnosis of “Current episode of major depression” and
“Previous episode of major depression” based on the SCID-I (see Table 2), indicating that the MBSR
group had fewer participants currently depressed compared to the other two groups. Considering that
this variable could impact the economic evaluation, subsequent analyses were adjusted for “Current
episode of major depression” among other covariates. Table 2 displays descriptive details for the
sociodemographic variables of this sample.
Table 3 contains the descriptive statistics of costs and outcomes at baseline and at 12 month
follow-up, split according to the three arms of the RCT, along with adjusted and unadjusted p values.
3.1. Baseline Costs

The analyses revealed that only the specialized health care services cost was significantly different
among study arms (adjusted p value = 0.02), indicating that TAU was the most expensive group in this
particular service with an average cost of approximately €660, higher than MBSR (approximately €540)
and FibroQoL (approximately €400). However, the other costs did not show any significant difference,
including direct and total costs.
3.2. Follow-Up Costs

For 12 month follow-up costs, we observed that primary health care services cost was significantly
lower for the MBSR group (approximately €200) than for the FibroQoL (approximately €320) and
for the TAU groups (approximately €360). Post hoc pairwise comparisons indicated that MBSR’s
primary health care costs were significantly lower than TAU’s (adjusted p value = 0.002) and presented
a marginal significance compared to the FibroQoL group (adjusted p = 0.06).
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Table 2. Baseline characteristics of patients with Fibromyalgia (FM) by treatment group.
MBSR (n = 68) FibroQoL (n = 68) TAU (n = 68) p

Gender (women, %) 66 (97.1%) 67 (98.5%) 67 (98.5%) 0.78
Age, mean (SD) 52.63 (8.03) 54.44 (7.69) 53.16 (8.39) 0.4
Marital status, n (%)
Single 2 (2.9%) 3 (4.4%) 1 (1.5%)
Married/living with a partner 53 (77.9%) 50 (73.5%) 55 (80.9%) 0.59
Separated/divorced 11 (16.2%) 9 (13.2%) 10 (14.7%)
Widowed 2 (2.9%) 6 (8.8%) 2 (2.9%)
Education level, n (%)
Illiterate 0 (0%) 1 (1.5%) 1 (1.5%)
Did not graduate from primary school 4 (5.9%) 1 (1.5%) 4 (5.9%)
Primary school 31 (45.6%) 37 (54.4%) 32 (47.1%) 0.21
Secondary school 31 (45.6%) 24 (35.3%) 28 (41.2%)
University 0 (0%) 5 (7.4%) 3 (4.4%)
Others 2 (2.9%) 0 (0%) 0 (0%)
Employment status, n (%)
Homemaker 10 (14.7%) 10 (14.7%) 4 (5.9%)
Paid employment 19 (27.9%) 21 (30.9%) 19 (27.9%)
Paid employment but in sick leave 6 (8.8%) 4 (5.9%) 4 (5.9%)
Unemployed with subsidy 8 (11.8%) 9 (13.2%) 11 (16.2%) 0.47
Unemployed without subsidy 8 (11.8%) 15 (22.1%) 9 (13.2%)
Retired/pensioner 9 (13.2%) 4 (5.9%) 10 (14.7%)
Temporal disability 1 (1.5%) 2 (2.9%) 1 (1.5%)
Others 7 (10.3%) 3 (4.4%) 10 (14.7%)
Clinical variables
Years of diagnosis, mean (SD) 14.46 (9.17) 11.28 (7.17) 13.68 (10.02) 0.14
Current episode of depression, n (%) 24 (35.3%) 39 (57.4%) 38 (55.9%) 0.02
Previous episode(s) of depression, n (%) 25 (36.8%) 20 (29.4%) 34 (50%) 0.04
Dysthymia, n (%) 14 (20.6%) 9 (13.2%) 8 (11.8%) 0.31
Daily FM-related medication
Analgesics, n (%) 21 (30.9%) 21 (30.9%) 15 (22.1%) 0.42
Anti-inflammatory, n (%) 17 (25%) 17 (25%) 24 (35.3%) 0.31
Opioids, n (%) 25 (36.8%) 21 (30.9%) 17 (25%) 0.33
Antiepileptic, n (%) 13 (19.1%) 11 (16.2%) 14 (20.6%) 0.8
Muscle relaxant, n (%) 2 (2.9%) 5 (7.4%) 3 (4.4%) 0.48
Antidepressants, n (%) 35 (51.5%) 30 (44.1%) 26 (38.2%) 0.3
Anxiolytics, n (%) 30 (44.1%) 33 (48.5%) 31 (45.6%) 0.87
Table 3. Summary statistics of the costs (total and disaggregated in components) and outcomes
according to treatment group.
MBSR FibroQoL TAU OMNIBUS Significance Test

Baseline (N = 204) n = 68 n = 68 n = 68 p Adjusted p
Primary health care services 349.6 (325.8) 322.4 (282.8) 316.4 (269.6) 0.78 0.81
Specialized health care services 537.6 (438.1) 398.5 (411.9) 661.9 (674.8) 0.01 0.02
Medical tests 455.8 (462.8) 474.2 (634.7) 424.3 (480.4) 0.86 0.94
FM-related medications 307.6 (488.6) 204.3 (262.6) 171.6 (282.5) 0.15 0.19
Direct costs 1650.7 (1069.9) 1399.4 (1006.5) 1574.3 (1220.6) 0.35 0.39
Indirect costs 667.8 (1951.1) 669.7 (1569.6) 1144.8 (2953.1) 0.45 0.24
Total costs 2318.4 (2417.6) 2069.1 (2075.5) 2719.1 (3783.9) 0.45 0.18
Outcomes
EQ-5D utility score (0 to 1) 0.50 (0.21) 0.48 (0.23) 0.53 (0.23) 0.44 0.28
EQ VAS (0 to 100) * 46.61 (21.82) 47.31 (19.91) 47.32 (18.51) 0.97 0.75
12-months Follow-up (N = 128) n = 44 n = 41 n = 43
Primary health care services 197.3 (233.4) 319.4 (312.3) 357.9 (301.8) 0.01 0.02
Specialized health care services 498 (485.3) 534.1 (552) 664.8 (754.3) 0.45 0.5
Medical tests 225.4 (360.3) 257.3 (280.4) 328.2 (417.6) 0.44 0.42
FM-related medications 235.9 (349.2) 189.8 (205.1) 255.4 (434.3) 0.56 0.58
Intervention (MBSR/FibroQoL) 702.5 (298.9) 578.1 (181.3) 0 (0) 0 0
Direct costs 1156.6 (938.3) 1300.6 (872.4) 1598.7 (1265.1) 0.17 0.13
Indirect costs 400.9 (1325.2) 714.6 (1905.8) 929.9 (2229.8) 0.36 0.1
Total costs 1557.5 (1626.9) 2015.2 (2122.1) 2528.7 (3017) 0.14 0.04
Outcomes
EQ-5D utility score (0 to 1) 0.57 (0.25) 0.53 (0.27) 0.45 (0.26) 0.11 0.05
EQ VAS (0 to 100 points) 52.41 (23.06) 42.44 (21.16) 44.98 (19.85) 0.09 0.21
QALY (0 to 1, on the basis of EQ-5D utility score) 0.54 (0.18) 0.50 (0.20) 0.48 (0.22) 0.34 0.05
Note: Data are presented as mean € cost (SD), except where otherwise is stated. Covariates: age, gender, marital
status, education level, employment status, duration of the illness since first diagnostic, current episode of major
depression baseline costs, and baseline outcomes, depending on the analyses considered. The mean sessions attended
per intervention were 5.3 for MBSR (no retreat included) and 5.8 for FibroQoL. Thirty-two participants (42.7%)
attended to the optional mindfulness retreat. * One missing value was found in this variable. EQ-5D = EuroQol
five-dimensional classification; EQ VAS = visual analogue scale; QALY = quality-adjusted life years.
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Another marginal significance appeared in the post hoc pairwise comparisons for the variable
“Medical tests costs”, indicating that the MBSR group had a lower value than the TAU group (adjusted
p value = 0.09). As could be expected, the intervention’s cost was also significantly different between
the groups, which could be attributed to one group (TAU) not receiving any intervention at all.
The comparisons regarding direct costs did not present statistical significance (adjusted
p value = 0.13), although post hoc analyses revealed that the MBSR group, with cost at approximately
€1160, was significantly lower than the TAU group, with cost at approximately €1600 (adjusted p value
= 0.02).
Focusing on indirect costs, the analyses revealed no significant differences between the three
groups (adjusted p value = 0.10), although the post hoc pairwise comparisons indicated that MBSR’s
associated indirect costs (approximately €400) were significantly lower than FibroQoL’s (approximately
€710, adjusted p value = 0.05) and TAU’s (approximately €930, adjusted p value = 0.05).
Finally, the total costs were significantly different between the three study arms (adjusted
p value = 0.04), as the MBSR group was less costly (approximately €1560) compared to the FibroQoL
(approximately €2020) and the TAU groups (approximately €2530). Post hoc pairwise analyses
showed that the MBSR group had significantly lower total costs compared to the FibroQoL (adjusted
p value = 0.02) and the TAU groups (adjusted p value = 0.02).
3.3. Baseline Quality of Life Outcomes

Outcomes at baseline were very similar between the three groups, ranging from 0.48 to 0.53 for the
EQ-5D utility scores and between 46 and 47 for the EQ VAS. The pairwise tests revealed no significant
differences (p > 0.05 in every case).
3.4. Follow-Up Quality of Life Outcomes

At 12 month follow-up, the between group differences were significant overall for the EQ-5D
utility score (adjusted p value = 0.05). The MBSR group had the highest value (0.57), and the TAU
group had the lowest value (0.45). On the other hand, no significant differences were observed in the
case of the EQ VAS (adjusted p value = 0.26). We calculated QALYs based on the EQ-5D utility score,
and we found significant differences between the three groups (adjusted p value = 0.05).
3.5. Cost Utility Analysis from the Government Perspective

As shown in Table 4, MBSR was found to be dominant compared with TAU. The incremental
costs (in €) were found to be significant in the base case analysis (completers) and the per-protocol
analysis, ranging from approximately €−1030 to €−1110. On the other hand, the incremental effect
was significant in the ITT analysis, in which 0.053 QALYs were gained with MBSR compared to TAU.
The EQ VAS score, however, did not improve significantly in any case, despite ranging between 7
and 12.
When comparing the two active groups, MBSR showed a significantly lower incremental cost
compared to FibroQoL using the completer sample (between €−70 and €−820), but no significant
differences were observed in the incremental effects. Here, FibroQoL achieved a slightly better outcome
in QALYs that translated into an ICER of €385,400/QALY, which cannot be considered a cost-effective
result. Under the other two analyses, the incremental costs did not present any significant difference,
ranging from €−540 to €−650. Regarding the incremental effects, they favored MBSR in all the cases,
but neither the EQ-5D utility score nor the EQ VAS, which ranged from 7 to 12 depending on the
sample used, showed any significant difference.
Finally, the comparison between FibroQoL and TAU indicated that the average incremental cost
ranged between €−250 and €−460, with FibroQoL showing lower costs than TAU, although such
difference was not found to be significant in any of the three samples considered. On the other hand,
the incremental effect for QALYs was significant (0.056) using the completer sample, although the EQ
VAS effect was slightly better for the TAU group, resulting in an ICER of €159/EQ VAS points gained,
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despite not being a significant difference. Under the two other analyses, the incremental effect was also
non-statistically significant but favored the FibroQoL group.
Table 4. Incremental cost, effect, and cost-effectiveness ratios from the government perspective.
Incremental Cost Incremental Effect

Mean Mean ICER
(95% Bootstrap CI) (95% Bootstrap CI)
MBSR vs TAU
Completers (n = 128)
QALY (EQ-5D) −1023.5 (−2024.7 to −270.5) 0.053 (−0.040 to 0.129) MBSR dominant
EQ VAS (0-100) * −1072 (−2048.5 to −273.6) 7.89 (−1.72 to 18.69) MBSR dominant
ITT (n = 204)
QALY (EQ-5D) −828.1 (−1699.4 to 43.2) 0.053 (0.004 to 0.101) MBSR dominant
EQ VAS (0-100) * −855.2 (−1727.6 to 17.3) 7.13 (−0.52 to 14.79) MBSR dominant
PPA (n = 107)
QALY (EQ-5D) −1036.6 (−1894.3 to −178.9) 0.080 (-0.060 to 0.220) MBSR dominant
EQ VAS (0–100) * −1108.6 (−1968.8 to −248.4) 12.23 (−2.33 to 26.78) MBSR dominant
MBSR vs FibroQoL
QALY (EQ-5D) −770.8 (−1401.4 to −172.4) -0.002 (-0.066 to 0.059) €385,400/QALY
EQ VAS (0-100) * −822.5 (−1529.1 to −195) 9.46 (-0.84 to 20.35) MBSR dominant
ITT (n = 204)
QALY (EQ-5D) −539.9 (−1214.6 to 134.8) 0.012 (−0.032 to 0.056) MBSR dominant
EQ VAS (0-100) * −575 (−1246.1 to 96.1) 6.68 (−1.01 to 14.37) MBSR dominant
PPA (n = 107)
EQ VAS (0-100) * −651.6 (−1328 to 24.8) 12.08 (−3.62 to 27.78) MBSR dominant
FibroQoL vs TAU
QALY (EQ-5D) −252.7 (−1176.6 to 536) 0.056 (0.006 to 0.172) FibroQoL dominant
EQ VAS (0-100) * −249.6 (−1164.5 to 654) −1.57 (−6.71 to 10.44) €159/EQ VAS
ITT (n = 204)
QALY (EQ-5D) −288.2 (−1307.9 to 731.6) 0.041 (−0.003 to 0.084) FibroQoL dominant
EQ VAS (0-100) * −280.1 (−1297 to 736.6) 0.45 (−7.31 to 8.22) FibroQoL dominant
PPA (n = 107)
QALY (EQ-5D) −453.8 (−1290.3 to 382.8) 0.069 (-0.010 to 0.149) FibroQoL dominant
EQ VAS (0-100) * −456.9 (−1301 to 387.1) 0.15 (−9.47 to 9.76) FibroQoL dominant
Note: Significant values (p < 0.05) are shown in bold. Covariates: gender, age, marital status, current episode of
major depression, educational level, and employment status. * Analyses using the EQ VAS score as outcome were
computed using one patient less in each case, due to missing data on this baseline variable. ICER = incremental
cost-effectiveness ratios.
Figure 2 shows the degree of uncertainty around the differences in costs and QALYs between the
groups from the government perspective in the completer sample.
3.6. Cost Utility Analysis from the Health Care Perspective

As shown in Table 5, results were in line with those found when considering the government
perspective, whereas incremental costs varied given the different cost aggregated used for this part of
the analysis.
When comparing MBSR and TAU, the first was again dominant as the incremental costs were
significantly lower, ranging between approximately €−420 and €−490. The incremental effect observed
for the QALYs was significant using the ITT sample (0.053, p = 0.03).
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Figure 2. Cost–utility plane of 1000 bootstrap replicated incremental cost–utility from the government
perspective (completer sample): (a) MBSR vs. TAU; (b) MBSR vs. FibroQoL; (c) FibroQoL vs. TAU.
Incremental costs of MBSR compared to FibroQoL ranged between €−120 and €−280 but were
not found to be significantly different. Similarly, the incremental effects did not show any significant
difference, although the EQ VAS score ranged from 7 to 12, depending on the sample. All the
incremental effects favored MBSR but the incremental QALYs using the completer sample, which
resulted in an ICER of €116,300/QALY gained and should not be considered a significant result.
Finally, the incremental costs of FibroQoL compared to TAU ranged between €−190 and €−320,
but none of them were significant. The incremental effect in QALYs was found to be significant for the
completer sample (0.056). All the incremental effects favored FibroQoL but the incremental EQ VAS
using the completer sample, which resulted in an ICER of €121/EQ VAS points gained and should not
be considered a significant result.
Although both scenarios presented similar results, it can be observed that, under the health care
perspective, the MBSR group achieved a significant reduction in incremental costs compared to TAU
in the three samples, including the ITT, which was not significant under the government perspective.
On the other hand, the significant reduction in incremental costs of MBSR compared to FibroQoL
taking the completer sample was lost when considering the health care perspective.
Figure S1 shows the degree of uncertainty around the differences in costs and QALYs between the
groups from the health care perspective in the completer sample.
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Table 5. Incremental cost, effect, and cost-effectiveness ratios from the health care perspective.
Incremental Cost Incremental Effect

Mean Mean ICER
(95% Bootstrap CI) (95% Bootstrap CI)
MBSR vs. TAU
QALY (EQ-5D) −420.7 (−883.8 to −34.9) 0.053 (−0.041 to 0.131) MBSR dominant
ITT (n = 204)
QALY (EQ-5D) −455.2 (−904.6 to −4.9) 0.053 (0.004 to 0.102) MBSR dominant
EQ VAS (0–100) * −483 (−929.5 to −36.5) 7.14 (−0.49 to 14.77) MBSR dominant
PPA (n = 107)
MBSR vs FibroQoL
QALY (EQ-5D) −232.6 (−572 to 129.6) −0.002 (−0.067 to 0.059) 116,300 €/QALY
EQ VAS (0–100) * −275.2 (−629.2 to 96.7) 9.47 (−1.03 to 20.24) MBSR dominant
ITT (n = 204)
PPA (n = 107)
FibroQoL vs TAU
FibroQoL dominant
QALY (EQ-5D) −188 (−696.2 to 227.8) 0.056 (0.007 to 0.173)
121 €/EQ VAS
EQ VAS (0–100) * −189.6 (−625.8 to 259.4) −1.57 (−10.49 to 6.68)
ITT (n = 204)
EQ VAS (0–100) * −217.8 (−655.9 to 220.3) 0.45 (−7.22 to 8.12) FibroQoL dominant
PPA (n = 107)
EQ VAS (0–100) * −319.4 (−748.8 to 110.1) 0.15 (−9.42 to 9.73) FibroQoL dominant
Note: Significant values (p < 0.05) are shown in bold. Covariates: sex, age, marital status, current episode of
major depression, educational level, and employment status. * Analyses using the EQ VAS score as outcome were
computed using one patient less in each case due to missing data on this baseline variable.
4. Discussion
The primary aim of the present study was to analyze the cost–utility of MBSR in a sample of
Spanish patients with FM, both from the government and the public health care system perspectives.
The intervention was compared to an active control group (i.e., the multicomponent intervention
FibroQoL) and to usual care, and the economic evaluation was performed in the context of a
12 month RCT.
The results of this study can be summarized as follows. MBSR (added to TAU) compared to
TAU alone was associated with lower direct and total costs in people with FM at 12 month follow-up.
This significant decrease of costs was mainly due to a reduction in the costs related to primary health
care services and indirect costs during the follow-up period for the MBSR group. The incremental
effect on quality of life, measured with QALYs, was significant when considering the ITT sample.
Both from the health care and the government perspectives, all ICERs were dominant for MBSR
independent of the approach (completers, ITT, or PPA) compared to TAU. These results are similar to
those observed in previous studies, as other non-pharmacological interventions have been described
as cost-effective when compared with usual care [14,22–25]. In line with Beard et al. [20], our findings
point in the direction of considering that there is a large proportion of patients with FM who remain
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insufficiently treated with standard pharmacotherapy and could benefit from coadjuvant interventions
such as MBSR.
When the two active groups (i.e., MBSR and FibroQoL, both added to TAU) were compared,
the only significant difference was observed in the reduction of total costs under the government
perspective in favor of MBSR (completers sample). This difference was based primarily on the reduction
of indirect costs, as no significant reduction in direct costs was observed (i.e., health care perspective).
Reducing indirect costs has been considered as one of the main target points for interventions addressed
to chronic pain management [52]. As stated by Hedman-Lagerlöf et al. [24], it is possible that reduction
of indirect costs was not only a consequence of reduced symptoms, but that engaging in work-related
activities may in turn lead to improvements in FM symptoms. In addition, indirect costs derived from
disability, unemployment, and/or early retirement have been associated with disease severity [53],
and it would be interesting to update the rates of absenteeism and disability considering the recently
proposed classification by Pérez-Aranda et al. [54], as this system already found significant differences
in indirect costs among clusters that were not observed using the classical cut-off-based classification
method. Considering that not all patients with FM respond equally to every treatment, including
MBSR, as the current RCT proved, studying how effective the different, already validated interventions
for FM are for each subtype of patient could be the next step toward the ideal of personalized medicine.
In terms of incremental effects on quality of life, no differences were found between MBSR and
FibroQoL, indicating that both interventions achieved a similar effect in the long term. This tendency
was already observed in the previous study based on this RCT [31], where MBSR was found as clearly
more efficacious than FibroQoL at post-treatment, but only significant improvements in fibromyalginess
(measured by the Fibromyalgia Survey Diagnostic Criteria [55]) and pain catastrophizing (measured
by the Pain Catastrophising Scale [56]) were observed at 12 month follow-up.
It seems reasonable to believe that effects of MBSR on quality of life might show a similar
long-term pattern as other outcomes, as it would be intimately related to some of the core FM
symptoms (e.g., functional impairment, anxiety and depression, perceived stress, and perceived
cognitive dysfunction). Based on what previous studies have demonstrated [57–60], this partial loss of
effect in the long-term could be attributed to a reduction in the frequency of practice of mindfulness
exercises once the intervention is over, which would imply that some FM symptoms and presumably
quality of life are particularly practice-dependent. Therefore, finding ways to enhance the frequency
and the quality of mindfulness home practice is an issue of great relevance to be studied in the future.
The comparison between FibroQoL and TAU indicated that the first produced a significant
incremental effect on quality of life on the completers sample, although no significant reduction in
costs was observed in any case beyond the perspective considered. Despite being dominant when
compared to TAU, FibroQoL was not as superior as it had been in a previous RCT [22] in which the
costs were reduced in a similar degree (approximately €−220), but the incremental quality of life was
notably higher (0.12). A possible explanation would be that in the previous RCT, the recruited patients
were already visited by the same professionals who conducted the FibroQoL program, which could
have enhanced the therapeutic alliance, a relevant factor in any treatment context and particularly in a
syndrome such as FM that is often associated with the experience of feeling stigmatized [61,62].
Considering previous findings on the cost–utility of different non-pharmacological interventions
for FM, we can observe that some, such as the spa treatment or the aquatic training, achieved a
significant incremental effect (0.04 and 0.131, respectively) but also higher incremental costs than usual
care, resulting in ICERs which ranged between €8000 and more than €30,000 per QALY gained [16,17].
Other interventions, such as GACT [14], achieved a similar improvement in QALYs (0.05 compared to
waiting list) as the one that MBSR achieved in the present study compared to TAU and reduced the costs
considerably more (approximately €−1900). Also, GACT was dominant compared to recommended
drugs under the health care perspective (approximately €−900). It is notable, however, that the GACT
group did not consume any medication during the trial, which undoubtedly reduced associated
costs. CBT, for its part, significantly reduced the costs compared to TAU (approximately €−2000) and
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recommended pharmacologic treatment (approximately €−2300), but no significant incremental effect

was observed [23]. The STreSS program, however, also a cognitive-behavioral intervention, did achieve
a significant incremental effect (0.035) compared to usual care as well as a significant cost reduction
in the long term [25]. Finally, the internet-delivered exposure therapy assessed by Hedman-Largelöf
et al. [24] not only achieved significant effects (0.07 QALYs gained) but also a great cost reduction
(approximately €−5000) compared to usual care. When comparing the incremental effects achieved by
the different interventions, one needs to bear in mind that the present study used the EQ-5D-5L, which
has been associated with smaller changes in quality of life than the EQ-5D-3L [63], the version that
most of the abovementioned studies used [14,17,22–24].
On the other hand, if we look at the cost–utility of MBIs for other medical conditions, the systematic
review conducted by Duarte et al. [26] concluded that, despite positive results being found for depression
and emotional unstable personality disorder, the small number of studies conducted (only five) and the
heterogeneity in the interventions (four studies assessed Mindfulness-Based Cognitive Therapy and
one MBSR) limited the generalizability of the findings. In this regard, our study extends the existing
evidence of the cost–utility of MBIs in this case and for FM the first time.
Limitations
Some limitations of this study cannot be overlooked. First, given that the economic evaluation
was not the primary objective when the original RCT was designed, an unexpectedly higher number of
missing baseline data in economic- and quality of life-related variables emerged, invalidating 21 of the
original 225 patients for the current study. Moreover, a considerably low follow-up rate (around 65%)
added to more missing cost–utility-related data in the 12 month follow-up assessment and yielded a
completer sample of only 128 patients. Even though regression models included bootstrapping with
1000 replications to address skewness within the data, the sample size in each study arm did not allow
a robust estimation of costs, and confidence intervals were large in most cases; therefore, the results
reported should be interpreted with caution.
Another limitation is that the randomization was not stratified by the presence of comorbid major
depression, which resulted in the MBSR group having significantly fewer participants with a current
episode of major depression compared to the other study arms. However, all reported analyses were
performed after adjusting for this variable.
Although it could be thought that public registries would be a better way to collect data on health
services use, self-reported data have been demonstrated to be of equal validity as registry-collected
data in health-economic assessment [24]. In our study, the CSRI version included recall over a
12 month period, a commonly used time frame in which underreporting is usually more frequent than
overreporting due to memory decay and memory biases such as reverse-telescoping (i.e., excluding
some events from the recall period) [64]. Some authors, such as Bellón et al. [65], strongly recommend
employing recall frames of at least 12 months to reduce memory biases present in patients’ responses
in short recall periods. We note that direct non-health care costs including out of pocket expenses, costs
of paid and unpaid help, travel expenses, and over the counter medication and other treatment use
(e.g., anti-constipation, vitamins, etc.) were not estimated.
Regarding the interventions, it needs to be considered that they were not fully equivalent. MBSR
included an optional 6 h retreat, surely increasing the cost of the intervention, which accentuates the
significant reduction in total costs that MBSR showed compared to FibroQoL. In terms of program
completion, here defined as having attended to at least six of the eight sessions of each program
(no retreat included in the case of MBSR), it was low (56% for MBSR and 65% for FibroQoL) but similar
to what has been observed in FM intervention studies [28]. This continues to be a difficult problem to
solve. Some authors have proposed strategies that could be implemented in further studies, such as
written commitments from all participants or makeup classes for those who missed a session [66].
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5. Conclusions
In summary, the results of the present work support that MBSR (added to TAU) is cost-effective
compared with the multicomponent intervention FibroQoL (also added to TAU) and TAU alone. This is
mainly because of a reduction in the 12 month follow-up incremental costs (€−1024 compared to TAU
and €−771 compared to FibroQoL; government perspective, completers sample) produced essentially
in primary health care services and indirect costs. Also, MBSR showed a significant incremental effect
in quality of life compared to TAU using the ITT sample (ΔQALYs = 0.053).
FM is a prevalent condition all around the world, however, our results are not necessarily
generalizable to all FM patients (our sample has a very small representation of men) nor to other
contexts—not only due to cultural differences but also importantly due to differences in how health
care systems are organized in other countries. These results support the cost–utility of MBSR for FM,
which is in line with previous findings regarding other non-pharmacological interventions such as
forms of CBT and ACT. These interventions may have potential to be cost-effective not only for FM
but also for treating other chronic pain conditions and/or central sensitivity syndromes (e.g., irritable
bowel syndrome, chronic fatigue syndrome, and multiple chemical sensitivity), but this would need
specific examination in future studies.
These findings add a substantial contribution to previous studies by presenting, for the first time,
an economic evaluation of an MBI for FM. Nonetheless, they should be considered with caution as,
among other limitations, the sample of each study arm did not allow robust estimations; if these results
were supported by further studies, offering MBSR as a coadjuvant intervention to usual care should be
considered as a therapeutic option in the public provision of healthcare.
Supplementary Materials: The following is available online at http://www.mdpi.com/2077-0383/8/7/1068/s1,

Figure S1: Cost-utility plane of 1000 bootstrap replicated incremental cost–utility from the health care perspective
(completer sample): (a) MBSR vs. TAU; (b) MBSR vs. FibroQoL; (c) FibroQoL vs. TAU. Table S1: CHEERS
Checklist. Items to include when reporting economic evaluations of health interventions.
Author Contributions: Conceptualization, J.V.L. and A.P.-A.; methodology, F.D. and A.P.-A.; software, F.D.;
validation, J.V.L., F.D. and A.P.-A.; formal analysis, F.D. and A.P.-A.; investigation, J.V.L.; resources, J.V.L.; data
curation, L.A.-R., N.A.-O. and A.P.-A.; writing—original draft preparation, A.P.-A., F.D. and J.V.L.; writing—review
and editing, A.F.-S., L.M.M., J.G.-C., M.T.P.-M. and M.K.; visualization, L.A.-R., N.A.-O. and M.T.P.-M.; supervision,
M.K.; project administration, J.V.L. and A.F.-S.; funding acquisition, J.V.L.
Funding: The study has been funded in part by the Instituto de Salud Carlos III (ISCIII) of the Ministry of
Economy and Competitiveness (Spain) through the Network for Prevention and Health Promotion in Primary Care
(RD16/0007/0005 & RD16/0007/0012), by a grant for research projects on health from ISCIII (PI15/00383) cofinanced
with European Union ERDF funds. The first listed author (A.P.-A.) has a FI predoctoral contract awarded by
the Agency for Management of University and Research Grants (AGAUR; FI_B00754). The third listed author
(A.F.-S.) has a “Sara Borrell” research contract from the ISCIII (CD16/00147). The sixth listed author (L.A.-R.) has a
FI predoctoral contract awarded by the Agency for Management of University and Research Grants (AGAUR;
FI_B00783). The last listed author (J.V.L.) has a “Miguel Servet” research contract from the ISCIII (CP14/00087).
Acknowledgments: The authors gratefully acknowledge the support of the staff and patients of the Department
of Rheumatology at the Parc Sanitari Sant Joan de Déu Hospital.
Conflicts of Interest: The authors declare no conflict of interest. The funders had no role in the design of the
study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, or in the decision to
publish the results.
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156
Journal of
Clinical Medicine
Article
Motor Imagery and Action Observation of Specific
Neck Therapeutic Exercises Induced Hypoalgesia in
Patients with Chronic Neck Pain: A Randomized
Single-Blind Placebo Trial
Luis Suso-Martí 1,2 , Jose Vicente León-Hernández 1,3 , Roy La Touche 1,3,4,5, *,
Alba Paris-Alemany 1,3,4,5 and Ferran Cuenca-Martínez 1,3
1 Motion in Brains Research Group, Institute of Neuroscience and Sciences of the Movement (INCIMOV),
Centro Superior de Estudios Universitarios La Salle, Universidad Autónoma de Madrid,
28023 Madrid, Spain
2 Department of Physiotherapy, Universidad CEU Cardenal Herrera, CEU Universities, 46115 Valencia, Spain
3 Departamento de Fisioterapia, Centro Superior de Estudios Universitarios La Salle,
Universidad Autónoma de Madrid, 28023 Madrid, Spain
4 Instituto de Neurociencia y Dolor Craneofacial (INDCRAN), 28008 Madrid, Spain
5 Instituto de Investigación Sanitaria del Hospital Universitario La Paz (IdiPAZ), 28046 Madrid, Spain
* Correspondence: roylatouche@yahoo.es; Tel.: +34-91-740-19-80; Fax: +34-91-357-17-30
Abstract: The aim of the present study was to explore the pain modulation effects of motor imagery
(MI) and action observation (AO) of specific neck therapeutic exercises both locally, in the cervical
region, and remotely. A single-blind, placebo clinical trial was designed. A total of 30 patients with
chronic neck pain (CNP) were randomly assigned to an AO group, MI group, or placebo observation
(PO) group. Pain pressure thresholds (PPTs) of C2/C3, trapezius muscles, and epicondyle were
the main outcome variables. Secondary outcomes included heart rate measurement. Statistically
significant differences were observed in PPTs of the cervical region in the AO and MI groups between
the preintervention and first postintervention assessment. Significant differences were found in
the AO group in the epicondyle between the preintervention, first and second post-intervention
assessments. Regarding heart rate response, differences were found in the AO and MI groups between
the preintervention and average intervention measurements. AO and MI induce immediate pain
modulation in the cervical region and AO also induces remote hypoalgesia. OA appears to lead to
greater pain modulation as well as a greater heart rate response, however, both should be clinically
considered in patients with CNP.
Keywords: motor imagery; action observation; chronic neck pain; pain modulation; pain neuroscience;
musculoskeletal pain
1. Introduction
Chronic neck pain (CNP) is a common musculoskeletal disorder with a high prevalence, and
is the fourth leading condition that generates significant disability [1,2]. Patients with CNP usually
present disturbances in postural control or neuromuscular control of the deep neck muscles associated
with the onset of the condition [3,4]. Therefore, specific neck therapeutic exercise (SNTE) training of
the deep neck musculature is widely used and might reduce pain and disability in patients with CNP
compared with other types of conservative treatment [5].
SNTE has also been shown to induce immediate pain modulation, similar to the hypoalgesia
induced by aerobic or isometric exercise [6,7]. Therefore, a central mechanism might be responsible

J. Clin. Med. 2019, 8, 1019
for pain modulation after exercise [8]. On the other hand, the mental practice paradigms of motor
simulation, such as action observation (AO) and motor imagery (MI), have recently been developed as
a neurocognitive treatment tool for chronic pain [9,10]. MI is defined as a dynamic mental process of
an action, without its actual motor execution [11]. AO evokes an internal, real-time motor simulation
of the movements that the observer perceives visually [12]. Both mental practice paradigms trigger the
activation of the neurocognitive mechanisms that underlie the planning and execution of voluntary
movements in a manner that resembles how the action is performed in real life [13–15]. AO and MI
might involve an autonomic nervous system (ANS) response. It has been shown that both MI and AO
lead to changes in the ANS that cause sympathetic responses, and the neurophysiological base appears
to be centrally controlled [16–18].
In recent years, both of these mental processes have been used in the acquisition of new motor
gestures, range-of-motion enhancements, or for chronic pain management [19–21]. Despite the
similarities of mental practice and exercise, it is uncertain whether MI or OA can induce immediate
pain modulation in a similar manner as real exercise in patients with CNP, which would open new
treatment approaches for these patients.
The aim of the present study was to explore the pain modulatory effects of MI and AO of SNTE
in the cervical region. Our objective was to evaluate the hypoalgesic effects induced by MI and AO,
both locally, in the cervical region, and remotely [6]. We hypothesized that MI and AO strategies
would induce hypoalgesia and would be associated with an increase in heart rate, whereas a placebo
observation (PO) did not.
2. Methods
2.1. Study Design

This study was a randomized, placebo clinical trial, with patient and evaluator blind, planned and
conducted in accordance with Consolidated Standards of Reporting Trials (CONSORT) requirements,
and was approved by a university ethics committee, with number CSEULS-PI-026/2019, Madrid, Spain.
This study was registered in the United States Randomized Trials Registry on clinicaltrial.gov
(trial registry number: NCT03905577). All patients completed the informed consent document prior to
the study.
2.2. Recruitment of Participants

The participants had been referred to the primary care physiotherapy service, had been diagnosed
with CNP by their family doctor, and met the study’s inclusion criteria at one physiotherapy center.
Participants were recruited between April 2019 and May 2019.
The inclusion criteria were as follows: (a) men and women aged between 18 and 65 years;
and (b) a medical diagnosis of CNP with at least six months of neck pain symptoms. Exclusion criteria
included the following: (a) patients with rheumatic diseases, cervical hernia or radicular pain, cervical
whiplash syndrome, neck surgeries, or a history of arthrodesis; (b) systemic diseases; (c) vision, hearing,
or vestibular problems; or (d) severe trauma or a traffic accident that had an impact on the cervical area.
All data were collected at the La Salle University Center for Advanced Studies. All the participants
were given an explanation of the study procedures, which were planned according to the ethical
standards of the Helsinki Declaration.
2.3. Randomization
Randomization was performed using a computer-generated random sequence table with a
non-balanced three-block design (GraphPad Software, Inc., San Diego, CA, USA). An independent
researcher generated the randomization list, and a member of the research team who was not involved
in the assessment of the participants or the intervention was in charge of the randomization and
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J. Clin. Med. 2019, 8, 1019
maintained the list. The patients included were randomly assigned to one of the three groups using
the random sequence list, ensuring concealed allocation.
2.4. Blinding
The assessments and treatments were performed by various therapists. The evaluator was
blinded to the participants’ group assignment. All the intervention procedures were performed by the
same physiotherapist who had experience in the field and was blinded to the purpose of the study.
Patients were blinded to their group allocation. In addition, a different researcher, blinded to the
objectives of the study, performed the data analysis.
2.5. Interventions
2.5.1. Action Observation Group

Patients in this group observed two SNTE typically used in the treatment of patients with CNP.
Both exercises were based on the motor gesture of craniocervical flexion (Figure 1). Patients in the AO
group performed the observation through a video of the continuous performance of both exercises
repeatedly during two series of 1 min for each exercise, with a total duration of 4 min. The participants
were seated with a laptop in front of them.
Figure 1. Specific therapeutic neck exercises included in the intervention. (A) Flexion-extension
resistance exercise. (B) Cranio–cervical flexion exercise.
The first exercise involved a resistance deep muscle contraction by performing continuous the
cranio-cervical flexo-extension gesture with the resistance of an elastic band (Figure 1A). The second
exercise consisted of maintaining the cervical spine in a neutral position in a sitting position and
performing a deep muscle contraction to flatten the curve of the neck by nodding with the head.
This task involves flexion of the cranium on the cervical spine with the deep cervical muscle contraction
(Figure 1B). Patients were instructed to just observe both movements on the monitor without executing
or imagining any movement.
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J. Clin. Med. 2019, 8, 1019
2.5.2. Motor Imagery Group

The patients in this group performed a motor imagery protocol of the same cervical exercises
observed by the AO group (Figure 1). Patients were instructed on the movements they had to
imagine by showing both exercises and the auditive precise instructions for each movement during the
intervention. Next, they were instructed to perform a guided third-person mental task of visual motor
imagery. For this intervention, the participants were guided by the therapist to imagine the SNTE,
trying to form a visual mental image or picture of both movements and attempting to visualize the
movement as clear and vivid as possible. The MI intervention of both exercises was performed during
two series of 1 min for each exercise, with a total duration of 4 min.
2.5.3. Placebo Observation Group

Patients in this group underwent a PO protocol. A video composed of only nature landscape clips
was visualized for 4 min, without visualizing any motor gesture. This kind of PO protocol has been
used in previous research [22,23].
2.6. Outcomes
2.6.1. Primary Outcomes
Pressure Pain Thresholds

A pressure pain threshold (PPT) is defined as the minimal amount of pressure at which a sense of
pressure first changes to pain. The mechanical pressure algometer (Wagner Instruments, Greenwich,
CT, USA) used in this study consisted of a round rubber disk (area 1 cm2 ) attached to a pressure
(force) gauge. The gauge displayed values in kilograms, but because the surface of the rubber tip
was 1 cm2 , the readings were expressed in kg/cm2 . The range of the pressure algometer values was
from 0 to 10 kg, in 0.1 kg intervals. The pressure was applied at a rate of 0.31 kg/s [24]. Previous
studies have reported an intraexaminer reliability of this procedure ranging from 0.6–0.97, whereas the
interexaminer reliability ranged from 0.4–0.98 [25].
PPTs were tested in four different locations. These sites included the angle of both the upper fibers
of the left and right trapezius muscles (5–8 cm superior medial from the superior angle of the scapula),
the zygapophyseal joint of C2/C3, and the nondominant lateral epicondyle. All the assessments were
performed in a quiet room. In order to familiarize the participants with the test procedure, pressure
was first applied to an area that would not be tested during the study. Three consecutive measurements
of the PPT at the four locations at intervals of 30 s and the mean of these three trials was used for the
data analysis [25].
2.6.2. Secondary Outcomes
Heart Rate
Heart rate (HR) was measured to determine how the patients were engaging in the interventions,
because HR is under autonomic nervous system control. The heart rate was recorded to quantify the
changes produced during the performance of the mental motor practice. The Garmin Forerunner VR
225 is a commercially available wrist-worn heart rate monitor that uses an optical green light sensor to
detect pulse rate, which represents HR. The Garmin Forerunner VR 225 was programmed with the
participants’ sex, age, weight, and height, and was fitted on the left forearm, according to the user
manual. Previous studies have shown moderate to strong validity of the Garmin Forerunner VR 225
versus traditional electrocardiography measures (Pearson r = 0.650–0.868).
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J. Clin. Med. 2019, 8, 1019
Motor Imagery Ability

The movement imagery questionnaire-revised (MIQ-R) is an eight-item self-report inventory used
to assess visual and kinesthetic motor imagery ability. Four different movements are included in the
MIQ-R, which is comprised of four visual and four kinesthetic items. For each item, participants read a
description of the movement. They then physically performed the movement and were instructed
to resume the starting position after finishing the movement and before performing the mental task,
which was to imagine the movement visually or kinesthetically. Next, each participant rated the ease
or difficulty of generating the mental image on a seven-point scale, in which 7 indicated “very easy to
see/feel” and 1 “very difficult to see/feel.” The internal consistencies of the MIQ-R have been adequate,
with Cronbach’s α coefficients ranging above 0.84 for the total scale, 0.80 for the visual subscale, and
0.84 for the kinesthetic subscale [26].
Mental Chronometry
Mental chronometry (MC) is a reliable measure that has been widely used to record objective
measurements of the ability to create mental motor images [27–29]. To assess MC, the time dedicated
to imagining each task of MIQ-R questionnaire was first recorded using a stopwatch. The time interval
between the command to start the task (given by the evaluator) and the verbal response at the conclusion
of the task (given by the participant) was recorded. After the motor imagery task, the participants were
asked to execute the real movement of the task, and the time dedicated to performing each task was
recorded using a stopwatch. Both time measurements were taken to obtain the temporal congruence
between both tasks. During motor imagery, spatial and temporal information were similar to those of
the physical execution, suggesting that the time taken to imagine the movement would be similar to
that needed for its real execution. MC was used to measure the temporal congruence between real and
imagined movements [28,30].
Pain-Related Fear of Movement

Pain-related fear of movement was assessed using the 11-item Spanish version of the Tampa Scale
for Kinesiophobia, whose reliability and validity have been demonstrated [31]. The Tampa Scale for
Kinesiophobia consists of two subscales, one related to fear of activity and the other related to fear
of harm. The final score can range between 11 and 44 points, with higher scores indicating greater
perceived kinesiophobia [31].
Pain Catastrophizing
The Spanish version of the Pain Catastrophizing Scale assesses the degree of pain catastrophizing
and is a reliable and valid form of measurement. It is composed of 13 items, with a three-factor
structure of rumination, magnification, and helplessness that must be answered with a numeric value
between 0 (not at all) and 4 (all the time), with a maximum score of 52 points, with higher scores
indicating greater pain catastrophizing [32].
Neck Disability
Disability was measured using the Spanish-validated Neck Disability Index (NDI), which consists
of 10 items related to daily functional activities. Each question is measured on a scale from 0
(no disability) to 5, and an overall score out of 100 is calculated by adding each item score together and
multiplying it by two. A higher NDI score indicates a patient’s greater perceived disability due to neck
pain. It has been shown to have high “test–retest” reliability and to have appropriate psychometric
properties [33].
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J. Clin. Med. 2019, 8, 1019
Physical Activity Level

The level of physical activity was objectified through the International Physical Activity
Questionnaire, which allows the participants to be divided into three groups according to their
level of activity: high, moderate, and low or inactive [34]. This questionnaire has shown acceptable
validity and psychometric properties for measuring total physical activity.
Visual Analogue Scale

A visual analogue scale (VAS) was used to measure pain intensity. The VAS is a 100-mm line with
two endpoints representing the extreme states “no pain” and “the maximum pain imaginable”. It has
been shown to have good retest reliability (r = 0.94, p < 0.001) [35,36].
2.7. Procedures
Each participant completed an informed consent document to participate in the study, in addition
to a set of questionnaires to complete before starting the intervention. These questionnaires included
psychometrics forms and a questionnaire about age, sex, medication, anthropometric measures,
pain duration, and the predominant pain location. The psychological variables were evaluated with
self-assessments and the pain intensity by VAS. Then, MIQ-R and mental chronometry were assessed.
The preintervention PPT measurements were made at the four sites by an external assessor, in random
order. Subsequently, an initial HR measurement was performed. The Garmin Forerunner VR 225
monitor was placed, the patients lay down for five minutes, and then sat upright for two more minutes.
In both positions, the patients were instructed to maintain a comfortable position and relaxed breathing,
with the aim of obtaining a baseline HR measurement. The first measurement was taken at the end of
seven minutes, just before the start of the intervention (preintervention measure). At this time and in a
sitting position, patients performed the AO protocol, MI or PO, according to the randomized group.
HR measurements were taken during the intervention. A measurement was recorded every 15 s for
four minutes; subsequently, the average of all the measurements was recorded (intervention average
measure). The postintervention HR was recorded at the end of the four minutes of the intervention
(postintervention measurement). Immediately after the intervention, a blinded evaluator measured the
PPTs in all four locations (post-1). Following this, patients were asked to sit relaxed and comfortably,
without movement, for 10 min, and the PPTs were again measured (post-2).

The statistical data analysis was performed using statistical SPSS software version 22.0
(SPSS Inc., Chicago, IL, USA). The normality of the variables was evaluated by the Shapiro–Wilk
test. Descriptive statistics were used to summarize the data for continuous variables and are presented
as mean ± standard deviation, 95% confidence interval. Additionally, we compared age, weight, and
height between groups with a one-way ANOVA to explore whether the groups were homogeneous at
baseline. The chi-squared test was used for the categorical variables that were presented as frequency
and percentage. A mixed model analysis of variance (ANOVA) was conducted to study the effect of the
between-participant “treatment group” factor in each of the three categories (AO, MI, and placebo) and
the within-participant “time” factor, also in each of the three categories (i.e., pre-, post-1, and post-2),
of all the dependent variables except for the HR. For the HR, the difference between the preintervention
measurement, average intervention measurement, and the immediate postintervention measurement
was evaluated (pre-, average intervention, post-1). A post hoc analysis with Bonferroni correction was
performed in the case of significant ANOVA findings for multiple comparisons between variables.
Effect sizes (d) were calculated according to Cohen’s method, in which the magnitude of the effect was
classified as small (0.20–0.49), moderate (0.50–0.79), or large (>0.8) [37]. The α level was set at 0.05 for
all tests.
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3. Results
A total of 30 patients with CNP were included and were randomly allocated into three groups of
10 participants per group (Figure 2). There were no adverse events reported in either group. All the
variables presented a normal distribution. No statistically significant differences were found between
groups for any of the primary variables, demographic data, or self-report variables at baseline between
the groups, except for educational level (p < 0.05) (Tables 1 and 2).
Figure 2. Study flow chart.
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Table 1. Descriptive statistics of sociodemographic data.
AO Group MI Group PO Group

Measures p Value
(n = 10) (n = 10) (n = 10)
Age 33.5 ± 14.25 30.6 ± 11.53 27.70 ± 6.39 0.520
Height (cm) 171.9 ± 0.80 173.10 ± 0.70 174 ± 0.40 0.798
Weight (kg) 66.7 ± 7.97 68.70 ± 4.8 69.5 ± 8.26 0.672
Pain intensity (VAS) 68.9 ± 13.95 75 ± 7.73 70.8 ± 9.36 0.437
Pain duration (month) 27.9 ± 17.99 26.2 ± 12.45 17.4 ± 10.05 0.212
Sex 0.875
Male 5 (50) 5 (50) 4 (40)
Female 5 (50) 5 (50) 6 (60)
Educational Level 0.03
Secondary education 3 (30) 5 (50) 0 (00)
College education 7 (70) 5 (50) 10 (100)
Marital Status 0.136
Single 7 (70) 3 (30) 5 (50)
Married 3 (30) 4 (40) 4 (40)
Divorced 0 (0) 3 (30) 1 (0)
Pain Location 0.530
Right 5 (50) 2 (20) 2 (20)
Left 3 (30) 5 (50) 4 (40)
Both 2 (20) 3 (30) 4 (40)
Values are presented as mean ± standard deviation or number (%); MI: motor imagery; AO: action observation; PO:
placebo observation; VAS: visual analogue scale.
Table 2. Descriptive statistics of self-reported and psychosocial data.
AO Group MI Group PO Group

Measures p Value
(n = 10) (n = 10) (n = 10)
PCS 31 ± 5.9 32.2 ± 6.71 33.1 ± 5.65 0.745
TSK-11 32.3 ± 6 33 ± 4.85 31.3 ± 3.93 0.633
NDI 30.5 ± 3.62 29.8 ± 3.82 32.1 ± 4.48 0.430
IPAQ 1760.6 ± 483.51 1713.85 ± 500.3 1785.7 ± 659.17 0.958
MIQ-R 47.4 ± 4.77 47.3 ± 7.86 48 ± 4.52 0.960
MC 3.65 ± 3.96 4.39 ± 5.7 4.71 ± 4.52 0.879
Values are presented as mean ± standard deviation or number (%); MI: motor imagery; AO: action observation; PO:
placebo observation; PCS: Pain Catastrophizing Scale; TSK: Tampa Scale of Kinesiophobia; NDI: Neck Disability
Index; IPAQ: International Physical Activity Questionnaires; MIQ-R: Movement Imagery Questionnaire-Revised;
MC: Mental Chronometry.
3.1. Primary Outcomes
3.1.1. Pressure Pain Threshold
C2/C3
The ANOVA revealed significant changes in the C2/C3 PPT measurement during group*time
(F = 3.04, p = 0.025, η2 = 0.185) and time (F = 10.74, p < 0.01, η2 = 0.285). The post hoc analysis revealed
significant intragroup differences (Table 3). Statistically significant differences were observed between
the preintervention assessment and the post-1 intervention in the AO and MI groups, with a moderate
effect size (p < 0.001, d = 0.74, and p = 0.004, d = 0.68, respectively) (Figure 3).
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Figure 3. Changes in the pressure pain threshold (PPT) C2/C3 measurement. *: p < 0.05; **: p < 0.001;
AO: action observation; MI: motor imagery group; PO: placebo observation group; Pre: pre-intervention
measurement; Post-1: first post intervention measurement (immediately after intervention); Post-2:
second post intervention measurement (10 min after intervention).
Table 3. Results of the PPT outcomes.
Mean ± SD Mean Difference (95% CI); Effect Size (d)

(a) Pre–Post 1
Measure Group (b) Pre–Post 2
Pre Post-1 Post-2 (c) Post 1–Post 2
(a) −0.41 * (−0.71 to 0.12); d = 0.68

MI 1.75 ± 0.54 2.17 ± 0.69 2.03 ± 0.60 (b) −0.27 (−0.66 to 0.11); d = 0.49
PPT
(c) 0.14 (−0.83 to 0.37); d = 0.21
(C2/C3)
(a) −0.54 ** (−0.84 to −0.25); d = 0.74
AO 1.79 ± 0.77 2.33 ± 0.68 2.15 ± 0.75 (b) −0.36 (−0.75 to 0.02); d = 0.47
(c) 0.18 (−0.05 to 0.40); d = 0.25
(a) −0.02 (−0.02 to 0.75); d = 0.07
PO 1.85 ± 0.35 1.88 ± 0.43 1.76 ± 0.55 (b) 0.09 (0.29 to 0.48); d = 0.19
(c) 0.11 (−0.11 to 0.33); d = 0.24
Mean difference (95% CI)
Effect size (d)
−0.03 (−0.69 to −0.16 (−0.86 to −0.13 (− 0.85 to
MI-AO
0.63); d = 0.06 0.54); d = 0.23 0.60); d = 0.17
−0.10 (−0.76 to 0.29 (−0.41 to 0.27 (−0.46 to
MI-PO
0.56); d = 0.22 0.99); d = 0.5 0.99); d = 0.47
−0.07 (−0.73 to 0.46 (−0.24 to −0.39 (−0.34 to
AO-PO
0.59); d = 0.1 1.11); d = 0.79 1.12); d = 0.59
(a) −0.49 * (−0.93 to −0.04); d = 0.52
MI 1.83 ± 0.89 2.32 ± 0.99 1.97 ± 0.73 (b) −0.14 (−0.60 to 0.32); d = 0.17
PPT
(c) 0.35 (−0.22 to 0.72); d = 0.40
(RT)
(a) −0.55 * (−0.99 to −0.11); d = 0.54
AO 1.86 ± 0.81 2.41 ± 1.16 2.26 ± 0.1.14 (b) −0.40 (−0.86 to 0.07); d = 0.40
(c) 0.16 (−0.21 to 0.52); d = 0.13
(a) 0.17 (−0.28 to 0.61); d = 0.29
PO 2.03 ± 0.59 1.86 ± 0.55 1.76 ± 0.34 (b) 0.27 (−0.19 to 0.74); d = 0.56
(c) 0.11 (−0.26 to 0.47); d = 0.21
Effect size (d)
−0.02 (−0.91 to −0.09 (−1.15 to 0.28 (−1.2 to
MI-AO
0.86); d = 0.03 0.98); d = 0.08 0.63); d = −0.40
−0.20 (−1.08 to 0.46 (−0.61 to 0.21 (−0.70 to
MI-PO
0.68); d = 0.26 1.52); d = 0.57 1.13); d = 0.36
−0.18 (−1.06 to 0.54 (−0.52 to 0.49 (−0.42 to
AO-PO
0.71); d = 0.23 1.61); d = 0.6 1.41); d = 0.59
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Table 3. Cont.
Mean ± SD Mean Difference (95% CI); Effect Size (d)

(a) Pre–Post 1
Measure Group (b) Pre–Post 2
Pre Post-1 Post-2 (c) Post 1–Post 2
(a) −0.46 * (−0.85 to −0.07); d = 0.54

MI 1.85 ± 0.77 2.30 ± 0.89 2.09 ± 0.69 (b) −0.24 (−0.66 to 0.17); d = 0.32
PPT
(c) 0.21 (−0.17 to 0.60); d = 0.26
(LT)
(a) −0.78 ** (−1.16 to −0.39); d = 0.99
(b) −0.37 (−0.79 to 0.04); d = 0.43
AO 2.01 ± 0.70 2.78 ± 0.85 2.38 ± 0.99
(c) −0.40 * (0.02 to 0.79); d = 0.43
(a) 0.10 (−0.28 to 0.49); d = 0.27

PO 1.78 ± 0.39 1.67 ± 0.41 1.68 ± 0.33 (b) 0.09 (−0.32 to 0.51); d = 0.27
(c) 0.01 (−0.39 to 0.38); d = 0.02
Effect size (d)
−0.16 (−0.90 to −0.48 (−1.34 to −0.29 (−1.12 to
MI-AO
0.57); d = 0.21 0.38); d = 0.55 0.53) d =0.33
−0.06 (−0.67 to 0.63 (−0.23 to 0.40 (−0.42 to
MI-PO
0.80) d = 0.11 1.49), d = 0.90 1.22); d = 0.75
0.23 (0.51 to 1.11 ** (0.25 to 0.69 (−0.13 to
AO-PO
0.96); d = 0.40 1.96); d = 1.66 1.51); d = 0.94
(a) −0.29 (−0.60 to −0.01); d = 0.36
MI 2.88 ± 0.74 3.16 ± 0.81 2.95 ± 0.78 (b) −0.08 (−0.21 to 0.62); d = 0.09
PPT
(c) 0.21 (−0.21 to 0.62); d = 0.26
(Epicondyle)
(a) −0.64 ** (−0.95 to −0.33); d = 0.95
AO 2.47 ± 0.70 3.1 ± 0.62 3.02 ± 0.84 (b) −0.56 * (−0.96 to −0.15); d = 0.71
(c) 0.07 (−0.49 to 0.34); d = 0.11
(a) 0.18 (−0.13 to 0.49); d = 0.26
PO 3.05 ± 0.54 2.87 ± 0.79 2.61 ± 0.85 (b) 0.44 * (0.03 to 0.84); d = 0.62
(c) 0.25 (−0.67 to 0.16); d = 0.31
Effect size (d)
0.41 (−0.35 to −0.06 (−0.79 to −0.07 (−1.01 to
MI-AO
1.16); d = 0.56 0.91); d = 0.08 0.87) d = 0.08
−0.18 (−0.94 to 0.30 (−0.55 to 0.34 (−0.59 to
MI-PO
0.58) d = 0.26 1.15), d= 0.36 1.28); d = 0.41
−0.58 (−1.34 to 0.24 (−0.61 to 0.41 (−0.53 to
AO-PO
0.18); d = 0.92 1.09); d = 0.32 1.35); d = 0.48
* p < 0.05; ** p < 0.001. AO: action observation group; MI: motor imagery group; PO: placebo observation group;
PPT: pressure pain threshold; RT: right trapezius measurement; LT: left trapezius measurement; pre: preintervention
measurement; Post-1: first post intervention measurement (immediately after intervention); Post-2: second post
intervention measurement (10 min after intervention).
Right Trapezius Muscle

The ANOVA revealed significant changes in the right trapezius muscle PPT measurement during
group*time (F = 3.42, p = 0.014, η2 = 0.202) and time (F = 4.75, p = 0.013, η2 = 0.15) The post hoc analysis
revealed significant intragroup differences (Table 3). Statistically significant differences were observed
between the preintervention assessment and the post-1 intervention in the AO and MI groups, with a
moderate effect size (p = 0.012, d = 0.54, and p = 0.028, d = 0.52, respectively) (Figure 4).
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Figure 4. Changes in the PPT right trapezius measurement. *: p < 0.05; AO: action observation;
MI: motor imagery group; PO: placebo observation group; Pre: pre-intervention measurement; Post-1:
first post intervention measurement (immediately after intervention); Post-2: second post intervention
measurement (10 min after intervention).
Left Trapezius Muscle

The ANOVA revealed significant changes in the left trapezius muscle PPT measurement during
group*time (F = 4.16, p = 0.005, η2 = 0.235) and time (F = 8.92, p < 0.001, η2 = 0.248). The post hoc
analysis revealed significant intragroup differences between the preintervention assessment and the
post-1 measurement, with a large effect size (p < 0.001, d = 0.99), and between the post-1 and the post-2
assessments in the AO group, with a moderate effect size (p = 0.037, d = 0.43) (Table 3). In addition,
statistically significant differences were observed in the MI group between the preintervention
assessment and the post-1 measurement, with a moderate effect size (p = 0.015, d = 0.54). Finally,
statistically significant differences were found between the AO and PO groups, with a large effect size
(p < 0.001, d = 1.66) (Figure 5).
Figure 5. Changes in the PPT left trapezius measurement. *: p < 0.05; **: p < 0.001; AO: action observation;
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Lateral Epicondyle
The ANOVA revealed significant changes in the lateral epicondyle PPT measurement during
group*time (F = 6.4, p < 0.001, η2 = 0.321) and time (F = 4.44, p = 0.016, η2 = 0.141). The post hoc analysis
revealed significant intragroup differences only in the AO group (Table 3). Statistically significant
differences were observed between the preintervention assessment and the post-1 measurement, with
a large effect size (p < 0.001, d = 0.95), and between the pre-intervention assessment and the post-2
measurement, with a moderate effect size (p = 0.005, d = 0.71). In addition, intra-group differences
were found in the PO group between the preintervention and post-2 intervention measurements, with
a moderate effect size (p = 0.032, d = 0.62) (Figure 6).
Figure 6. Changes in the PPT epicondyle measurement. *: p < 0.05; **: p < 0.001; AO: action observation;
3.2. Secondary Outcomes
Heart Rate
The ANOVA revealed significant changes in heart rate during group*time (F = 18.52, p < 0.001,
η2 = 0.578) and time (F = 85.74, p < 0.001, η2 = 0.761). The post hoc analysis revealed significant
intragroup differences in the MI and AO groups between the preintervention assessment and the
intervention average assessment (p < 0.001 in both groups, d = 0.48 and d = 0.67, respectively).
Statistically significant differences were observed between the preintervention assessment and the
postintervention measurement, with a large effect size in the AO and MI groups (p < 0.001 in both groups,
d = 1.3 and d = 0.84, respectively). In addition, in both groups, statistically significant differences were
found between the intervention average measurement and postintervention measurement (p < 0.001
in both groups, d = 0.42 and d = 0.7, respectively).
Statistically significant intergroup differences were found between the AO and PO groups in the
intervention average measurement (p < 0.001; d = 1.4). In addition, significant intergroup differences
were found in the postintervention measurement between the MI and AO groups, with a large effect
size (p = 0.042, d = 1.10), and between the AO and PO groups (p = 0.001, d = 1.92) (Table 4).
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Table 4. Results of heart rate measurement.
Mean ± SD Mean Difference (95% CI); Effect Size (d).

(a) Pre-Intervention
Measure Group (b) Pre–Post
Pre Intervention Post
(c) Intervention–Post
(a) −2.54 ** (−4.09 to −0.97) d = 0.48

MI 72.3 ± 5.38 74.84 ± 4.99 77.3 ± 6.4 (b) −5 ** (−7.15 to −2.85); d = 0.84
HR (c) −2.47 ** (−3.74 to −1.2) d = 0.42
(a) −4.38 ** (−5.94 to −2.82) d = 0.67
AO 75.7 ± 6.77 80.08 ± 6.24 84.8 ± 7.19 (b) −9.1 ** (−11.24 to −6.95); d = 1.3
(c) −4.72 ** (−5.99 to −3.45) d = −0.7
(a) −0.52 (−2.08 to 1.04) d = −0.09
PO 71.6 ± 5.42 72.12 ± 5.05 72.6 ± 5.4 (b) −1 (−0.73 to 2.73); d = −0.18
(c) −0.48 (−1.75 to 0.79); d = −0.09
Effect size (d)
−3.4 (−10.13 to −5.24 (−11.48 to 0.99); −7.5 * (−14.77 to −0.23);
MI-AO
3.33); d = −0.55 d = −0.92 d = 1.10
−0.7 (−6.02 to 7.43); 2.72 (−3.52 to 8.95); 4.7 (−2.57 to 11.97); d =
MI-PO
d = −0.12 d = −0.54 −0.79
−4.1 (−2.63 to 7.96 * (1.73 to 14.19); 12.2 ** (−19.47 to
AO-PO
10.82); d = −0.66 d = 1.4 −4.93); d = 1.92
* p < 0.05; ** p < 0.001. AO: action observation group; MI: motor imagery group; PO: placebo observation group; HR:
heart rate; pre: preintervention measure; intervention: average intervention measure; post: postintervention measure.
4. Discussion
The aim of the present study was to explore the immediate modulatory pain effects of MI and
AO of SNTE in the cervical and remote regions. Our results show that both MI and AO induced an
immediate pain modulation response in the cervical region (post-1), however, it was not sustained in
the second measurement after the intervention. In the epicondyle, only AO induced pain reduction
between the preintervention measurement and both postintervention measurements. AO and MI
interventions provoked an increase in HR, however, AO showed significant differences in comparison
with the PO and MI groups.
Exercise-induced hypoalgesia is a well-documented phenomenon. Although most research has
demonstrated modulating effects on pain by aerobic exercise, O’Leary et al. have shown that performing
SNTEs, similar to those employed in the present study, produced local hypoalgesic responses in the
cervical region [6]. According to the literature, AO and MI might provoke cortical activations similar
to the real movement execution; thus, it is possible that the overlapping of cortical areas between real
execution and mental practice could explain our findings [38,39]. In this regard, Beinert et al. found
no differences in PPTs between performing and imagining motor control exercises of the flexor neck
musculature in patients with neck pain. These data suggest that there is probably a top-down central
mechanism responsible for hypoalgesia, according to our results [40]. However, Beinert et al. found no
differences in the PPTs of the cervical region after an MI or AO intervention of the articular position
error task [41]. These controversial data appear to be related to the imagined or observed task. It is
possible that if the selected movement is able to trigger pain or fear responses in patients during real
execution, the pain modulation response might be lower if it is performed mentally. This result has
also been found in studies using functional magnetic resonance, that show the activation of cortical
areas related to pain processing after the mental practice of painful movements [42]. In this regard,
Forkmann et al. examined the relationship between painful stimuli and cortical encoding of visual
stimuli [43]. Their results showed that when a visual stimulus was accompanied with a painful input,
there was a decrease in the activity of the hippocampus associated with a lower encoding of the
visual stimulus. It is possible that if an imagined or observed painful movement activates brain areas
similar to a real painful stimulus, the coding of visual information might also be influenced, affecting
pain modulation.
In addition to the pain-trigger responses, another relevant factor could be pain-related fear.
Previous research has shown that high levels of fear of movement directly affect the periaqueductal gray
through the amygdala, which might have a direct negative effect on endogenous pain modulation [44].
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The study by de-la-Puente-Ranea et al. showed hypoalgesic responses after complete cervical
rotation movements in patients with CNP, although this movement could be considered painful or
fear-associated in these patients [45]. However, the levels of patients’ fear of movement were low, and
it is possible that low fear of movement levels could influence these results in a manner opposite to the
aforementioned findings of Beinert et al. We therefore suggest that MI and AO might produce relevant
hypoalgesic responses, but it is necessary to consider factors such as pain-related fear or the possible
pain-trigger responses related to the imagined or observed movement.
A relevant finding of the present study is that MI and AO produced pain modulation responses
compared to PO. This finding is important because previous studies have suggested that distraction
might be a mechanism involved in pain modulation produced by mental practice [46,47]. Although
in the present study no immersive strategies were used that could provoke greater distraction,
other mechanisms are required to explain the hypoalgesia induced by mental practice. In addition
to the aforementioned top-down mechanism, additional hypotheses have been proposed concerning
interactions between pain modulation and heart rate, which were also found in this study, suggesting
a systemic pain modulatory effect. Previous research has investigated manual therapy hypoalgesia
models, showing that hypoalgesia is related to increased ANS activity [48,49]. In addition, patients with
chronic pain experience maladaptive neuroplastic changes that could lead to impaired cortical-motor
representation and diminished cortical excitability [50,51]. In this regard, previous studies have shown
that both AO and MI can cause an increase in cortical representation and excitability, influencing areas
such as the primary motor cortex or the dorsal premotor cortex [52,53]. Larsen et al. showed that
MI and AO could induce an increase in cortical excitability, which was associated with a decrease in
pain perception [54]. These findings are consistent with those obtained by Volz et al., in which pain
modulation was observed after AO training, which was associated with increased cortical excitability
of the motor cortex. This outcome is also directly related to the neural networks related to pain
modulation through corticothalamic networks, as well as changes in neural plasticity [55,56].
On the other hand, our results showed that the AO provoked greater local and remote hypoalgesic
responses and triggered a higher HR increase compared with MI. Possible differences between AO and
MI remain unclear and more research is needed. HR is under autonomic control, which could give an
estimate of the physiological responses produced by both interventions, although other measurements,
such as skin conductance or temperature, are necessary to establish whether AO or MI caused increased
activity of the autonomic nervous system. However, one of the main difficulties in interventions with
mental motor practice is to know if the patient was engaging to the intervention in the correct form.
Our HR date showed that in both groups, patients were engaged in the intervention, although in the
AO group the HR increase was higher compared to the MI group. One potential factor that could
influence this outcome is the exercises selected for the intervention. The selection of these exercises
was based on their extensive clinical application, the pain modulation effects found with their real
execution, and the intent to prevent fear in their execution. Fear responses to movements perceived as
dangerous have been associated with increases in ANS activity and pain intensity [57,58]. However,
a significant point to note is that MI requires a good ability to imagine and is less effective in people
with poorer imaginative ability [59]. Some aspects, such as imagining the body segment movement,
the complexity or familiarity of the movement, as well as levels of physical activity, have all been
related to MI performance ability. SNTE exercises are highly difficult to imagine, due to the fact that
they require motor learning of unknown, complex, and high precision movements. This could result in
less mental effort performed by patients in the MI group, due to their inability to imagine the exercises,
and less effort is associated with decreased ANS responses and might therefore be associated with
decreased hypoalgesic responses [60,61]. Another hypothesis in this aspect is that the difficulty in
imagining the exercises could provoke a mental stress in the patients of the MI group that could be
related to the hypoalgesia. The stress-inducing hypoalgesia phenomenon has been previously reported
in the scientific literature and may be an alternative explanation to the results obtained [62]. In addition,
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patients with chronic pain have a decreased ability to create mental motor images, which could also be
related to our results [63].
4.1. Clinical Implications

The results of the present study showed that AO and MI could provoke pain modulatory effects
in the cervical region. The implementation of mental practice in patients with persistent pain, is
highly relevant, as they could be performed in clinical environments where in the early stages, it is
not possible to perform motor gestures in a real way due to the presence of pain or psychosocial
variables, like fear of movement. These tools offer opportunities to improve the different stages of
rehabilitation for patients with dysfunctional and maladaptive pain. In addition, this approach could
increase the effectiveness of the current treatments, thus, they should be considered due to their simple
implementation and cost-effectiveness in everyday daily routines or clinical practice. In addition,
mental practice may have additional positive effects on motor learning or increase patient adherence to
exercising the rehabilitation process. Future studies should continue to investigate the benefits of AO
and MI in patients with chronic pain, as well as their implementation in clinical practice.
4.2. Limitations
This study presents some limitations. First, the sample size was small, and thus, the results should
be considered with caution. In addition, the results have only been considered in the short term,
and the duration and type of intervention might have been insufficient for greater increases in pain
modulation in patients with CNP, especially in the MI group. Second, changes in clinical pain were
not evaluated. Longer mental practice interventions may determine changes in clinical pain, which is
certainly a very relevant aspect. More research is needed to determine the role of mental practice in
pain modulation in patients with chronic pain.
5. Conclusions
Both the AO and MI of specific neck exercises are able to induce immediate pain modulation
of the cervical region. Although both strategies led to increases in PPTs, AO appears to have led to
greater local and remote pain modulation, as well as a greater response from the ANS. More research is
needed in this area on the role and additional benefits of mental practice in terms of pain modulation
and its implementation in clinical practice.
Author Contributions: Conceptualization, L.S.-M., F.C.-M. and R.L.T.; Methodology, L.S.-M. and F.C.-M.; Software,
N/A; Validation, L.S.-M., J.V.L.-H. and R.L.T.; Formal Analysis, L.S.-M., F.C.-M. and R.L.T.; Investigation, L.S.-M.
and J.V.L.-H.; Resources L.S.-M. and F.C.-M.; Data Curation, F.C.-M and J.V.L.-H.; Writing–Original Draft
Preparation, L.S.-M., F.C.-M, J.V.L.-H. and R.L.T.; Writing–Review & Editing, L.S.-M, A.P.-A., J.V.L.-H. and
R.L.T.; Visualization, L.S.-M., F.C.-M and J.V.L.-H.; Supervision, L.S.-M., J.V.L.-H., A.P.-A. and R.L.T.; Project
Administration, R.L.T and A.P.-A.; Funding Acquisition, N/A.
Acknowledgments: We thank La Salle University Center for Advanced Studies for making this study possible, as
well as all the participants in the study.
Conflicts of Interest: The authors declare that they have no conflicts of interest. This study did not receive any
specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
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174
Journal of
Clinical Medicine
Article
Moderate and Stable Pain Reductions as a Result of
Interdisciplinary Pain Rehabilitation—A Cohort
Study from the Swedish Quality Registry for Pain
Rehabilitation (SQRP)
Åsa Ringqvist 1 , Elena Dragioti 2 , Mathilda Björk 3 , Britt Larsson 2 and Björn Gerdle 2, *
1 Department of Neurosurgery and Pain Rehabilitation, Skåne University Hospital, SE-221 85 Lund, Sweden;
asa.ringqvist@skane.se
2 Pain and Rehabilitation Centre, and Department of Medical and Health Sciences, Linköping University,
SE-581 85 Linköping, Sweden; elena.dragioti@liu.se (E.D.); britt.larsson@liu.se (B.L.)
3 Department of Social and Welfare Studies, Linköping University, SE-602 21 Norrköping, Sweden;
mathilda.bjork@liu.se
* Correspondence: bjorn.gerdle@liu.se; Tel: +46-763-927-191
Received: 10 June 2019; Accepted: 20 June 2019; Published: 24 June 2019
Abstract: Few studies have investigated the real-life outcomes of interdisciplinary multimodal pain
rehabilitation programs (IMMRP) for chronic pain. This study has four aims: investigate effect
sizes (ES); analyse correlation patterns of outcome changes; define a multivariate outcome measure;
and investigate whether the clinical self-reported presentation pre-IMMRP predicts the multivariate
outcome. To this end, this study analysed chronic pain patients in specialist care included in the
Swedish Quality Registry for Pain Rehabilitation for 22 outcomes (pain, psychological distress,
participation, and health) on three occasions: pre-IMMRP, post-IMMRP, and 12-month follow-up.
Moderate stable ES were demonstrated for pain intensity, interference in daily life, vitality, and
health; most other outcomes showed small ES. Using a Multivariate Improvement Score (MIS), we
identified three clusters. Cluster 1 had marked positive MIS and was associated with the overall worst
situation pre-IMMRP. However, the pre-IMMRP situation could only predict 8% of the variation in
MIS. Specialist care IMPRPs showed moderate ES for pain, interference, vitality, and health. Outcomes
were best for patients with the worst clinical presentation pre-IMMRP. It was not possible to predict
who would clinically benefit most from IMMRP.
Keywords: chronic pain; musculoskeletal pain; patient care team; rehabilitation; treatment outcome
1. Introduction
Pain is an unpleasant experience with complex interactions between sensorimotoric, affective,
and cognitive brain networks. As such, pain, especially chronic pain, is influenced by and interacts
with physical, psychological, social, and contextual factors [1–3]. One-fifth of the European population
has moderate to severe chronic pain conditions [4]. These conditions are associated with psychological
distress, low health, sick leave, and high socioeconomic costs [5]. Therefore, a biopsychosocial (BPS)
framework should be considered in clinical practice [6–8].
Unlike single/unimodal interventions, interdisciplinary multimodal pain rehabilitation programs
(IMMRPs) for chronic pain—an interdisciplinary treatment according to the International Association
for the Study of Pain (IASP)—distinguish themselves as well-coordinated complex interventions.
Typically, IMMRPs are based on cognitive behavioural therapy (CBT) models (including Acceptance
Commitment Therapy, ACT) and are administered over several weeks to months [9–12]. The
Swedish programs generally include group activities such as pain education, supervised physical

J. Clin. Med. 2019, 8, 905
activity, training in simulated environments, and CBT coordinated by an interdisciplinary team

(e.g., physician, occupational therapist, physiotherapist, psychologist, and social worker) based on
a BPS framework [9–12]. The components of IMMRP are most often chosen based on the available
evidence for unimodal interventions for chronic pain, for example, with respect to education, exercise,
psychological interventions, and interventions for return to work. The core goals of rehabilitation
programs in general [13] and especially for patients with chronic pain [14] are broad and multifactorial in
combination with the individualised goals of the patient. These include increased ability to participate
in valued activities such as work. Hence, IMMRP is a complex intervention [13,15] and, unlike
pharmacological intervention, focusses on the whole person rather than just biochemical processes,
implying complex patient conditions matched with complex IMMRPs [16,17]. The components of
IMMRP can be active independently or interdependently [15], resulting in a combination of effects
explained by known and unknown mechanisms. The effects are assumed to be greater than the sum of
its components [18].
Systematic reviews (SRs) have generally reported higher efficacy both on a general level
and for specific outcomes of IMMRP compared with single-treatment or treatment-as-usual
programs [10,12,19–23]. SRs and Randomised Controlled Trials (RCTs) may be associated with
risk for bias resulting from, for example, an unrepresentative selection of patients and researcher
allegiance [24–26]. Thus, it is necessary to investigate whether the evidence obtained from SRs and
RCTs can be replicated within a consecutive non-selected flow of patients in practice settings using
prospective observational cohort study designs such as practice-based evidence (PBE). PBE has also
been applied in the field of rehabilitation research [27]. The importance of such an approach is
also emphasised in the real-effectiveness medicine framework [28]. IMMRPs are time consuming
and expensive, even when most of the activities are group-based. From an ethical, individual, and
socioeconomic perspective, it is indeed remarkable to note the lack of studies investigating effect sizes
(ES) in patient populations in real-life practice settings. A recent study from two Swedish university
clinics reported effect sizes of 0.51–0.61 (i.e., moderate ES) for two pain intensity variables at 12-month
follow-up [29]. These effect sizes should be confirmed in larger studies based not only on patients
at university hospitals, but also on specialist units in general. It would be motivating for patients to
endure increases in pain, which is often observed in clinical practise during the start-up period of
rehabilitation characterised by an increase in activity levels, if it were known that the long-term effects
include the reduction of pain levels.
Complex interventions such as IMMRP should have several outcomes measured at multiple
levels and strategies for handling multiple outcomes [17,30]. IMMRPs are evaluated using many
outcomes. For example, one SR including 46 RCTs reported nine outcomes per RCT (median) [10].
However, outcomes are not usually divided into primary and secondary outcomes [10]. In addition,
although it is most likely that changes in several of the selected outcomes are correlated, most SRs of
IMMRPs evaluate the outcomes as independent from each other. Patterns of potential correlations
(i.e., multivariate correlation patterns) are mainly unknown/uninvestigated, even though they could
give valuable information regarding how to optimise IMMRPs. Hence, there is a need to develop
clinically applicable ways to evaluate the multiple outcomes of MMPRs both for individual patients
and within research studies.
The above knowledge gaps motivated this PBE study of chronic pain patients based on patient
reported outcome measures (PROMs) from the Swedish Quality Registry for Pain Rehabilitation
(SQRP) [31]. This registry offers an opportunity to investigate clinical outcomes and patterns of
change, since all the relevant specialist care units throughout Sweden deliver data to SQRP. Hence,
this PBE study has the general aim of investigating the effects of IMMRP in specialist care in Sweden
considering the multivariate complexity of outcomes. We hypothesised that IMMRP in special care
is associated with small-to-medium ES, that changes in outcomes generally are intercorrelated, and
that the baseline situation (pre-IMMRP) can predict the multivariate outcomes. More specifically, we
defined the following four aims:
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J. Clin. Med. 2019, 8, 905
• To investigate the outcome effect sizes of IMMRP immediately post-IMMRP and at

12-month follow-up.
• To analyse the multivariate correlation patterns of changes in outcomes of IMMRP: pre-IMMRP
versus post IMMRP and pre-IMMRP versus 12-month follow-up.
• To define a multivariate outcome measure of IMMRP.
• To investigate if the clinical self-reported presentation pre-IMMRP can predict the multivariate
outcome measure.
2. Materials and Methods
2.1. The Swedish Quality Registry for Pain Rehabilitation (SQRP)

The SQRP, recognised by the Swedish Association of Local Authorities and Regions, receives
data from all specialist care units in Sweden [31]. The SQRP is based on PROM questionnaires
that capture biopsychosocial data such as the patient’s background, pain distribution and intensity,
pain-related cognitions, and psychological distress symptoms (e.g., depression and anxiety), as well as
activity/participation aspects and health-related quality of life variables. Patients complete the PROM
questionnaires on up to three occasions: (1) during assessment at the first visit to the unit (pre-IMMRP);
(2) immediately after the IMMRP (post-IMMRP); and (3) at the 12-month follow-up (FU) after IMMRP
discharge (12-month FU).
2.2. Subjects
This study included SQRP data from women and men ≥18 years old with complex chronic
(≥3 months) non-malignant pain who were referred to specialist pain and rehabilitation units
(i.e., specialist care centres) between 2008–2016. These patients can be characterised as complex,
as their health profiles included psychiatric comorbidities such as depression and anxiety, low levels of
acceptance, high levels of kinesiophobia, decreased working life and participation in social activities,
and/or did not respond to routine pharmacological/physiotherapeutic treatments delivered in a
monodisciplinary fashion. Strict inclusion and exclusion criteria for inclusion in the registry is not
available, since this is a registry study of patients with complex chronic pain conditions referred from
mainly the primary care to specialist care in Sweden. A minority of patients were referred from other
specialist clinics e.g., orthopedic and rheumatology clinics. The following general inclusion criteria for
IMMRP were used: (i) disabling chronic pain (on sick leave or experiencing major interference in daily
life due to chronic pain); (ii) age 18 years and above; (iii) no further medical investigations needed; and
(iv) written consent to participate and attend IMMRP. General exclusion criteria for IMMRP included
severe psychiatric morbidity, abuse of alcohol and/or drugs, diseases that did not allow physical
exercise, and specific pain conditions with other treatment options available (i.e., red flags).
The proportions of patients within primary health care with chronic pain conditions are not
exactly known, but 10–20% are estimates [32,33]. Furthermore, the proportion of chronic pain patients
within primary health care that are referred to specialist clinics is not known.
The study was conducted in accordance with the Helsinki Declaration and Good Clinical Practice
and approved by the Ethical Review Board in Linköping (Dnr: 2015/108-31). All the participants
received written information about the study and gave their written consent.
2.3. Variables
Background variables that were collected pre-IMMRP and symptom-related self-reported variables
that were collected at all three times (pre, post, and 12-month FU) were used in the analyses. The
variables and instruments used are mandatory for the units registering their data with the SQRP.
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J. Clin. Med. 2019, 8, 905
Background Variables
The following background variables were collected: age (years), gender (man or woman),
education level, and country of birth. Education level was dichotomised into university and the other
alternatives (i.e., upper secondary school, elementary school, or other); this variable was labelled as
University. Country of birth was dichotomised as from Europe and outside Europe and labelled as
Outside-Europe. In addition, self-reported pain duration (days), persistent pain duration (days), and
number of days off work (Days no work) were obtained.
Pain distribution was registered using 36 predefined anatomical areas (18 on the front and 18 on
the back of the body) and the patients registered the areas with pain: (1) head/face, (2) neck, (3) shoulder,
(4) upper arm, (5) elbow, (6) forearm, (7) hand, (8) anterior aspect of chest, (9) lateral aspect of chest,
(10) belly, (11) sexual organs, (12) upper back, (13) low back, (14) hip/gluteal area, (15) thigh, (16) knee,
(17) shank, and (18) foot. The number of areas with pain (range: 1–36) were summed, and the obtained
variable was denoted as the Pain Region Index (PRI).
2.4. Repeated Self-Reported Measures

For reports of the psychometric aspects of the self-reported measures, the reader is referred to
other studies summarising these [7,34–36].
2.4.1. Pain Aspects

Pain intensity average during the previous seven days was registered using a 0–10 (0 = no pain
and 10 = worst possible pain) numeric rating scale (NRS)—NRS-7days.
2.4.2. The Multidimensional Pain Inventory (MPI)

MPI is a 61-item self-report questionnaire that measures the psychosocial, cognitive, and
behavioural effects of chronic pain [37,38]. Part 1 consists of five scales: Pain severity—measuring
several aspects of the pain experience (MPI-Pain-severity); Interference—pain-related interference
in everyday life (MPI-Pain-interfer); Perceived Life Control (MPI-LifeCon); the level of affective
distress (MPI-Distress); and Social Support—perceived support from a spouse or significant others
(MPI-SocSupp). Part 2 assesses the perception of responses to displays of pain and suffering from
significant others and consists of three scales: Punishing Responses (MPI-Punish); Solicitous Responses
(MPI-Solict); and Distracting Responses (MPI-Distract). Part 3 measures to what extent the patients
participate in various activities using four scales. These scales can be combined into a composite
scale—the General Activity Index (MPI-GAI)—which was used in the present study [39].
2.4.3. Psychological Distress Variables

Symptoms of anxiety and depression were registered using the Hospital Anxiety and Depression
Scale (HADS) [40,41]. This instrument comprises seven items in each of two subscales: depression
(HADS-D) and anxiety (HADS-A) symptoms. Both subscale scores have a range of 0 to 21. A score of 7
or less in each subscale indicates a non-case, a score of 8–10 indicates a possible case, and a score of 11
or more indicates an almost definite case [40].
2.4.4. The Short Form Health Survey (SF36)

The Short Form Health Survey (SF36) attempts to represent multidimensional health concepts and
measurements of the full range of health states, including levels of well-being and personal evaluations
of health [42]. Scores are standardised into eight dimensions with a scale from 0 to 100 where higher
scores indicate a better perception of health [42]: (1) physical functioning (sf36-pf), physical activity
level including activities of daily living; (2) role limitations due to physical functioning (sf36-rp), to
what extent physical health limits the performance of work and other regular activities; (3) bodily
pain (sf36-bp), pain and related disability; (4) general health (sf36-gh), evaluation of health situation;
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J. Clin. Med. 2019, 8, 905
(5) vitality (sf36-vt), how rested and energetic; (6) social functioning (sf36-sf), disturbances of social life
due to physical or mental illness; (7) role limitations due to emotional problems (sf36-re), difficulties in
performing work or other regular activities due to emotional problems; and (8) mental health (sf36-mh),
anxiety and depressive symptoms. Based on the eight scales, a physical summary component and a
mental (psychological) summary component can be calculated, but these two summary component
variables were not used in the present study.
2.4.5. The European Quality of Life Instrument (EQ-5D)

The European Quality of Life Instrument (EQ-5D) captures a patient’s perceived state of
health [43–45]. The first part of the instrument defines five dimensions: mobility, self-care, usual
activities, pain/discomfort, and anxiety/depression. Each of these were measured at three levels. An
EQ-5D-index is derived by applying a formula that essentially attaches values (weights) to each of the
levels in each dimension. The collection of index values (weights) for all the possible EQ-5D states is
called a value set. Most EQ-5D value sets have been obtained from a standardised valuation exercise
where a representative sample of the general population in a country/region is asked to place a value
on EQ-5D health states. The EQ5D also measures the self-estimation of today’s health according to
a 100-point scale, which is a thermometer-like scale (EQ-VAS) with defined end points (high values
indicate good health and low values indicate bad health).
2.4.6. Estimations of Changes in Pain and in Life Situation

The patients post-IMMRP and at the 12-month FU estimated the degree of positive change in
pain (Change-pain) and in their ability to handle life situations in general (Change-life situation). The
Change-pain item was rated on a five-point Likert scale from markedly increased pain (0) to markedly
decreased pain (4). The Change-life situation item was rated on a five-point Likert scale from markedly
worsened (0) to markedly improved (4).
2.5. Statistics
All the statistics were performed using the statistical package IBM SPSS Statistics (version 24.0)
and SIMCA-P+ (version 15.0; Umetrics Inc., Umeå, Sweden). A probability of <0.001 (two-tailed) was
accepted as the criteria for significance due to the large number of subjects.
The text and tables generally report the mean value ± one standard deviation (±1 SD) together
with a median and range of continuous variables. Percentages (%) are reported for categorical variables.
The detailed analyses also report 95% confidence intervals (95% CI). SQRP uses predetermined
rules when handling single missing items of a scale or a subscale; details about this have been
reported elsewhere [29]. To compare groups, we used Student´s t-test for unpaired observations,
analysis of variance (ANOVA with post hoc test if significant difference), and Chi square test. Effect
sizes (ES; Cohen’s d) for within-group analysis were computed using a calculator when appropriate
(https://webpower.psychstat.org/models/means01/effectsize.php). Hedges’ g, which provides a measure
of effect size weighted according to the relative size of each sample, was used for between ES using
a calculator (https://www.socscistatistics.com/effectsize/default3.aspx). The absolute effect size was
considered very large for values ≥ 1.3, large for values between 0.80–1.29, moderate for values between
0.50–0.79, small for values between 0.20–0.49, and insignificant for values < 0.20 [46].
Common methods such as logistic regression (LR) and multiple linear regression (MLR) can
quantify the level of relations of individual factors but disregard interrelationships among different
factors and thereby ignore system-wide aspects [47]. Moreover, such methods assume variable
independence when interpreting results [48], and there are several risks when considering one variable
at a time [49]. To account for our aims, the problems related to handling missing data (see below),
and the risks associated with multicollinearity problems (see above), we used advanced multivariate
analyses (MVDA).
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Hence, using SIMCA-P+, we applied advanced Principal Component Analysis (PCA) for the
multivariate correlation analyses of all investigated variables and Orthogonal Partial Least Square
Regressions (OPLS) for the multivariate regressions. These techniques do not require normal
distributions of the included variables [50]. Note that the PCA of SIMCA-P+ differs considerably from
the simpler version implemented (e.g., the version used in SPSS).
PCA extracts and displays systematic variation in the data matrix. All the variables were
log transformed before the statistical analyses if data were skewed. Using PCA, we analysed the
multivariate correlation pattern for the changes in the 22 outcome variables for all the subjects.
Note that changes in outcomes are calculated so that a positive value indicates an improvement.
A cross-validation technique was used to identify nontrivial components (p). Variables loading on
the same component p were correlated, and variables with high loadings but with opposing signs
were negatively correlated. Variables with high absolute loadings were considered significant. The
obtained components are per definition not correlated and are arranged in decreasing order with respect
to explained variation. The loading plot reports the multivariate relationships between variables.
A corresponding plot reporting the relationships between subjects (i.e., t-scores) can also be used
(score plot), and each subject receives a score (t) for each of the significant components. The t-score
was used to calculate a Multivariate Improvement Score (MIS). R2 describes the goodness of fit—the
fraction of sum of squares of all the variables explained by a principal component [51]. Q2 describes the
goodness of prediction—the fraction of the total variation of the variables that can be predicted using
principal component cross-validation methods [51]. Outliers were identified using two methods: score
plots in combination with Hotelling’s T2 and distance to model in the X-space. No extreme outliers
were detected.
OPLS was used for the longitudinal multivariate regression analyses of the t-scores of the PCA
mentioned above using pre-IMMRP data (i.e., baseline data) [51]. The variable influence on projection
(VIP) indicates the relevance of each X-variable pooled over all dimensions and Y-variables—the group
of variables that best explain Y. VIP ≥ 1.0 was considered significant if VIP had a 95% jack-knife
uncertainty confidence interval non-equal to zero. p(corr) was used to note the direction of the
relationship (positive or negative). This is the loading of each variable scaled as a correlation coefficient,
and thus standardising the range from −1 to +1. [50] p(corr) is stable during iterative variable selection
and comparable between models [50]. Thus, a variable/regressor was considered significant when
VIP > 1.0. For each regression, we report R2 , Q2 , and the p-value of a cross-validated analysis of variance
(CV-ANOVA). SIMCA-P+ uses the Non-linear Iterative Partial Least Squares (NIPALS) algorithm to
handle missing data: maximum 50% missing data for variables/scales and maximum 50% missing data
for subjects.
To identify clusters based on the t-scores of the PCA mentioned above, we performed hierarchical
clustering analysis (HCA). Based on the identified clusters (subgroups) defined by HCA, we performed
partial least squares discriminant analysis (PLS-DA). In addition, we applied a bottom–up HCA to
the principal component score vectors using the default Ward linkage criterion to identify relevant
subgroups of patients. HCA can find subtle clusters in the multivariate space. In the resulting
dendrogram, clusters were identified and, based on these groups, we performed PLS-DA using group
belonging as the Y-variable and the psychometric data as predictors (X-variables). The PLS-DA model
was computed to identify associations between the X-variables and the subgroups. Based on the HCA
defined clusters, traditional inferential statistics (ANOVA including post hoc tests when appropriate)
were computed using SPSS.
3. Results
3.1. Background Data

There were 14,666 chronic pain patients registered in the SQRP that fulfilled the inclusion criteria:
chronic pain; >18 years of age; and completed the SQRP questionnaire before and on at least one of the
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two time points after the IMMRP. More than half (60%) of the patients answering the questionnaires
pre-IMMRP and post-IMMRP also answered the questionnaires at 12-m FU. Most of the patients (76.3%)
were women, 25.2% had studied at university, and 10.4% were born outside of Europe. More men
were born outside Europe (men: 13.4% versus women: 9.5%; Chi2 = 43.437, p < 0.001), and fewer men
had university education (men: 18.0% versus women: 27.4%; Chi2 = 123.672; p < 0.001). Continuous
background variables are shown in Table 1. Women were slightly younger than men (42.9 ± 10.7
versus 44.5 ± 10.7; p < 0.001) and reported more spreading of pain according to PRI (15.4 ± 8.8 versus
10.8 ± 7.0; p < 0.001). The other variables in Table 2 were not affected by gender.
Table 1. Continuous background variables; mean ± SD and 95% confidence intervals (95% CI).
95% CI 95% CI
Variables Mean ± SD
Lower Bound Upper Bound
Age (years) 43.2 ± 10.7 43.3 43.9
Days no work 1055 ± 2461 968 1095
Pain duration 3057 ± 3341 2970 3170
Persistent pain duration 2368 ± 2980 2239 2414
PRI 15.4 ± 8.6 15.1 15.6
Notes: SD = standard deviation; CI = confidence intervals; PRI = Pain Region Index.
Table 2. Outcome variables at baseline (pre-IMMRP) and immediately after IMMRP (post-IMMRP).
Statistical comparisons are presented furthest to the right together with effects sizes (i.e., Cohen’s d).
Effect sizes in bold were moderate, i.e., Cohen’s d ≥ 0.50. IMMRP: interdisciplinary multimodal pain
rehabilitation programs.
Baseline vs.
Pre-IMMRP Post-IMMRP
After IMMRP
N Mean SD Mean SD p-Value Cohen’s d
NRS-7days 14,146 6.86 1.72 5.95 2.09 <0.001 0.45
HADS-A 14,774 9.00 4.76 7.78 4.55 <0.001 0.32
HADS-D 14,772 8.49 4.44 6.70 4.31 <0.001 0.47
MPI-Pain-severity 14,692 4.39 0.93 3.87 1.16 <0.001 0.52
MPI-Pain-interfer 14,552 4.38 1.02 3.94 1.19 <0.001 0.49
MPI-LifeCon 14,687 2.72 1.10 3.30 1.18 <0.001 0.47
MPI-Distress 14,697 3.46 1.26 2.89 1.38 <0.001 0.42
MPI-Socsupp 14,618 4.16 1.34 3.95 1.35 <0.001 0.21
MPI-punish 13,054 1.74 1.36 1.72 1.33 0.037 0.02
MPI-protect 12,999 2.98 1.40 2.85 1.38 <0.001 0.12
MPI-distract 13,048 2.54 1.19 2.56 1.17 0.043 0.02
MPI-GAI 14,676 2.44 0.84 2.63 0.82 <0.001 0.26
EQ-5D-index 13,989 0.26 0.31 0.39 0.33 <0.001 0.40
EQ-VAS 13,777 41.22 19.09 50.99 21.38 <0.001 0.44
sf36-pf 14,253 52.76 20.58 57.67 21.17 <0.001 0.30
sf36-rp 13,945 12.53 24.40 22.46 33.12 <0.001 0.30
sf36-bp 14,268 24.36 14.49 32.96 17.41 <0.001 0.52
sf36-gh 13,988 41.70 20.22 46.69 21.88 <0.001 0.29
sf36-vt 14,206 23.95 18.48 35.67 22.76 <0.001 0.54
sf36-sf 14,229 47.29 25.19 54.93 25.91 <0.001 0.30
sf36-re 13,701 42.77 42.92 51.15 43.48 <0.001 0.18
sf36-mh 14,194 55.03 21.35 62.55 21.55 <0.001 0.38
NRS-7days = Pain intensity as measured by a numeric rating scale for the previous seven days; HADS = Hospital
Anxiety and Depression Scale; MPI = Multidimensional Pain Inventory; EQ-5D-index = The index of the European
quality of life instrument; EQ-VAS = The European quality of life instrument thermometer-like scale; sf36 = The
Short Form (36) Health Survey. For explanations of the subscale abbreviations, see Methods.
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3.2. Pairwise Comparisons of Repeated Measures

The results for pre-IMMRP and post-IMMRP are shown in Table 2. Significant improvements
were generally found except for two of the three scales of the second part of the MPI. In addition, the
comparisons between pre-IMMRP and the 12-month FU generally revealed significant improvements
except for one of the scales on the second part of the MPI (Table 3). Some outcomes were associated
with moderate effect sizes. For the pre-IMMRP versus post-IMMRP comparisons, three variables
had moderate effects sizes: MPI-pain-severity, sf36-bp, and sf36-vt (Table 2). At the 12-month FU,
MPI-pain-severity and sf36-bp were associated with moderate effect sizes; this was also the case for
MPI-pain-interference and EQ5d-index (Table 3). However, generally small effect sizes were found
for the significant improvements (Tables 2 and 3). The variables of the second part of the MPI had
insignificant effect sizes both post-IMMRP and 12-month FU.
Table 3. Outcome variables at baseline (pre-IMMRP) and at the 12-month follow-up (FU). Statistical
comparisons are presented furthest to the right together with effects sizes (i.e., Cohen’s d). Effect sizes
in bold were moderate (i.e., Cohen’s d ≥ 0.50).
Baseline vs. Pre 12-Month

12-Month Follow-Up IMMRP FU
N Mean SD Mean SD p-Value Cohen’s d
NRS-7days 8568 6.84 1.72 5.78 2.32 <0.001 0.47
HADS-A 8865 8.73 4.69 7.38 4.70 <0.001 0.33
HADS-D 8865 8.18 4.37 6.74 4.66 <0.001 0.35
MPI-Pain-severity 8904 4.36 0.91 3.71 1.33 <0.001 0.56
MPI-Pain-interfer 8829 4.34 1.02 3.73 1.37 <0.001 0.54
MPI-LifeCon 8871 2.77 1.10 3.28 1.27 <0.001 0.40
MPI-Distress 8889 3.42 1.27 2.92 1.45 <0.001 0.35
MPI-Socsupp 8830 4.17 1.33 3.77 1.42 <0.001 0.35
MPI-punish 7824 1.69 1.34 1.69 1.35 0.676 0.01
MPI-protect 7784 2.96 1.39 2.78 1.40 <0.001 0.16
MPI-distract 7811 2.52 1.17 2.45 1.17 <0.001 0.06
MPI-GAI 8859 2.47 0.83 2.64 0.86 <0.001 0.20
EQ-5D-index 8844 0.27 0.31 0.44 0.34 <0.001 0.50
EQ-VAS 8607 41.90 19.29 52.96 22.87 <0.001 0.46
sf36-pf 8459 53.07 20.30 59.73 22.57 <0.001 0.36
sf36-rp 8301 13.07 24.91 27.74 36.32 <0.001 0.39
sf36-bp 8458 24.60 14.11 35.41 20.05 <0.001 0.56
sf36-gh 8342 42.59 20.49 47.35 23.52 <0.001 0.25
sf36-vt 8441 24.96 18.79 34.41 23.85 <0.001 0.41
sf36-sf 8459 48.95 25.50 57.66 27.05 <0.001 0.32
sf36-re 8159 44.69 43.17 55.60 43.53 <0.001 0.22
sf36-mh 8435 56.34 21.15 62.70 22.53 <0.001 0.30
NRS-7days = Pain intensity as measured by a numeric rating scale for the previous seven days; HADS = Hospital
Anxiety and Depression Scale; MPI = Multidimensional Pain Inventory; EQ-5D-index = The index of the European
quality of life instrument; EQ-VAS = The European quality of life instrument thermometer-like scale; sf36 = The
Short Form (36); Health Survey; FU = Follow-up. For explanations of the subscale abbreviations see Methods.
3.3. Patients Not Participating in the 12-Month FU

There were only small differences between those reporting PROM data at the 12-month FU
and those not reporting their situation pre-IMMRP (Supplementary Table S1). Although those not
reporting had a somewhat worse situation for most of the PROM variables, the differences were of no
clinical importance.
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3.4. Estimations of Changes in Pain and in Life Situation

At both post-IMMRP and 12-month FU, most patients reported that their pain situation had
improved as well as their ability to handle their life situation (Table 4).
Table 4. Estimations of pain situation (Change-pain) and in the ability to handle life situation in general
(Change-life situation) made immediately after IMMRP (post-IMMRP) and at the 12-month FU.
Change-Pain Post-IMMRP 12-Month FU

n % n %
0. Markedly increased pain 447 3.2 225 2.6
1. Partially increased pain 1517 11 590 6.9
2. No change 4008 29.1 2905 34
3. Partially diminished pain 6178 44.9 3662 42.8
4. Markedly diminished pain 1607 11.7 1174 13.7
Total 13 757 100 8 556 100
Change-Life situation Post-IMMRP 12-Month FU
n % n %
0. Markedly deteriorated 74 0.5 108 1.3
1. Partially deteriorated 248 1.8 282 3.3
2. No change 1923 13.9 1615 18.8
3. Partially improved 8412 60.9 4628 54
4. Markedly improved 3161 22.9 1937 22.6
Total 13 818 100 8 570 100
FU = Follow-up.
3.5. Multivariate Correlation Pattern of Changes in Outcomes

PCAs of the changes (i.e., the difference) were performed for pre-IMMRP versus post-IMMRP
and pre-IMMRP versus 12-month FU. Significant models were achieved for both analyses (Table 5).
Similar patterns were obtained for the first significant component of the two PCAs (Table 5). The first
component of both analyses, reflecting the most important variations, showed that changes in HAD-D,
MPI-pain-severity, MPI-pain interference, MPI-control, MPI-distress, sf-36-bp, sf-36-vt, sf-36-sf, and
sf36-mh were most important and intercorrelated significantly. Hence, it was obvious that the changes
in outcome variables are intercorrelated. That is, rather than representing 22 independent variables,
the multivariate analyses show that most changes in these variables are highly intercorrelated.
At 12-month FU, the PCA also identified two additional components (Table 5). The second
component mainly reflected the intercorrelation pattern between the social support scale of the MPI
and the scales of part 2 of the MPI. A third significant component only explaining 6% of the variation
in the dataset was also obtained in the analysis of changes at the 12-month follow-up versus baseline
(Table 5).
The loading plot (i.e., the intercorrelations between variables of the two most important components
for the changes pre IMMRP versus 12-month FU) is shown in Figure 1 (Figure 1a is a graphic presentation
of the first two components reported in Table 5). Figure 1b shows the corresponding score plot (i.e., the
relationships between subjects/patients). Each patient can be described with a score (t-score) for each
significant component. Patients with high positive t-scores on the first component show prominent
changes in the important variables constituting the first component, whereas patients near zero do
not benefit, and patients with negative t-scores (located to the left in the score plot) deteriorate in the
multivariate context. Hence, the t-score of the first component of both analyses can be considered as a
Multivariate Improvement Score, in the following denoted MIS-post-IMMRP and MIS-12-month FU.
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Table 5. Principal component analysis (PCA) of changes pre-IMMRP vs. post-IMMRP (left part) and
pre-IMMRP vs. 12-month FU (right part). The significant components (p) are shown. Absolute loadings
≥ 0.25 are shown in bold to facilitate interpretation. Changes in outcomes are calculated so that a
positive value indicates an improvement.
Changes Pre-IMMRP vs. Changes Pre-IMMRP vs.

Post-IMMRP 12-Month FU
p[1] p[1] p[2] p[3]
diff-NRS-7days 0.23 0.23 −0.15 0.29
diff-HADS-A 0.23 0.22 0.19 −0.33
diff-HADS-D 0.26 0.25 0.17 −0.24
diff-MPI-Pain-sever 0.27 0.27 −0.16 0.26
diff-MPI-Pain-interfer 0.26 0.28 −0.11 0.10
diff-MPI-LifeCon 0.26 0.25 0.09 −0.05
diff-MPI-distress 0.27 0.26 0.13 −0.21
diff-MPI-SOCsupp −0.03 −0.07 0.41 0.21
diff-MPI-punish 0.07 0.08 0.32 0.11
diff-MPI-protect −0.02 −0.02 0.51 0.33
diff-MPI-distract 0.01 0.00 0.45 0.36
diff-MPI-GAI 0.12 0.15 0.00 0.07
diff-EQ-5D-index 0.22 0.22 −0.07 0.12
diff-EQ-VAS 0.22 0.23 −0.03 0.09
diff-sf36-pf 0.20 0.21 −0.14 0.20
diff-sf36-rp 0.19 0.21 −0.10 0.17
diff-sf36-bp 0.26 0.27 −0.15 0.25
diff-sf36-gh 0.21 0.21 0.02 0.02
diff-sf36-vt 0.27 0.26 0.03 −0.03
diff-sf36-sf 0.25 0.24 0.05 −0.09
diff-sf36-re 0.18 0.17 0.13 −0.26
diff-sf36-mh 0.27 0.25 0.21 −0.30
R2 0.31 0.36 0.10 0.06
Q2 0.25 0.31 0.04 0.02
N 14,666 8851
diff = change in a certain variable; p = principal component; NRS-7days = Pain intensity as measured by a numeric
rating scale for the previous seven days; HADS = Hospital Anxiety and Depression Scale; MPI = Multidimensional
Pain Inventory; EQ-5D-index = The index of the European quality of life instrument; EQ-VAS = The European
quality of life instrument thermometer-like scale; sf36 = The Short Form (36) Health Survey; FU = Follow-up. For
explanations of the subscale abbreviations see Methods.
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Figure 1. Cont.
(a)
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186
(b)
Figure 1. Loading plot of changes (pre-IMMRP vs. 12-month follow-up) in the 22 outcome variables—i.e., the relationships between the changes (a) and score plot
((b); the relationships between the patients). diff = change in a certain variable; NRS-7days = Pain intensity as measured by a numeric rating scale for the previous
seven days; HADS = Hospital Anxiety and Depression Scale; MPI = Multidimensional Pain Inventory; EQ-5D-index = The index of the European quality of life
instrument; EQ-VAS = The European quality of life instrument thermometer-like scale; sf36 = The Short Form (36) Health Survey; For explanations of the subscale
abbreviations, see Methods.
J. Clin. Med. 2019, 8, 905
3.6. Identification of Subgroups Based on the Multivariate Improvement Scores (MIS)

An HCA based on MIS-post-IMMRP was performed. Three subgroups/clusters were identified.
Based on the HCA, a PLS-DA model with two predictive components was obtained with group
belonging as the Y-variable (R2 = 0.35; Q2 = 0.35; CV-ANOVA p < 0.001; n = 14,666). Using a
similar approach, we performed an HCA based on MIS-12-month FU. This analysis identified three
subgroups/clusters. Based on the HCA, a PLS-DA model with two predictive components was obtained
with group belonging as the Y-variable (R2 = 0.37; Q2 = 0.37; CV-ANOVA p < 0.001; n = 8851).
The MIS (i.e., t-score) showed clear positive values (i.e., improvements) for cluster 1 and negative
scores (i.e., deterioration) for cluster 3 (Tables 6 and 7). Cluster 2 was an intermediary cluster with
overall slightly positive improvements. Prominent effect sizes in the pairwise comparisons were
observed post-IMMRP: cluster 1 versus cluster 2 = 3.33; cluster 1 versus cluster 3 = 5.36; and cluster 2
versus cluster 3 = 2.77; 12-month FU: cluster 1 versus cluster 2 = 2.92; cluster 1 versus cluster 3 = 4.99;
and cluster 2 versus cluster 3 = 2.34. Thus, distinct differences in improvement levels were detected
between the three clusters.
To facilitate the understanding of the identified clusters, the clusters were compared for the
variables in each PCA (Tables 6 and 7). The three clusters differed significantly for all changes according
to the ANOVAs performed. The post hoc tests showed that 20 of the 22 changes post-IMMRP differed
significantly between all three clusters. The corresponding figure at 12-month FU was 21 of 22 changes.
The estimations of changes in pain (Change-pain) and in management of life (Change-life situation)
were not included in the PCAs and thus not included in the calculations of MIS. However, these
estimations showed a similar pattern: the most prominent positive changes were in cluster 1, and the
least positive changes were in cluster 3 (Tables 6 and 7).
In the next step, the identified three clusters of both analyses were compared for their pre-IMMRP
values (Tables 8 and 9). For the clusters obtained post-IMMRP (Table 8), small irrelevant cluster
differences existed for age. The proportion with university education was significantly highest in
cluster 1 and lowest in cluster 3, although the differences were small. Generally, cluster 1 was associated
with the worst situation for the most variables followed longitudinally except for social support, two of
the scales of Section 2 of the MPI, and sf36-pf. In contrast, cluster 3 had the best situation, and cluster 2
was intermediate (Table 8). A very similar pattern was found when using the clusters obtained from
the 12-month FU (Table 9).
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Table 6. Clusters from hierarchical clustering analysis (HCA) based on Multivariate Improvement Score (MIS) (t-scores) of the first component of the PCA for the
changes in outcomes from pre-IMMRP to post-IMMRP (denoted MIS post-IMMRP). To facilitate understanding, the changes for all the outcomes are shown (mean,
SD, and 95% confidence interval). The two bottom rows show the estimations of changes (not included in PCA and the calculation of MIS).
Cluster 1 (15.0%) Cluster 2 (54.1%) Cluster 3 (30.8%)

95% 95% 95%
N Mean SD N Mean SD N Mean SD ANOVA
CI CI CI
J. Clin. Med. 2019, 8, 905
Variables LB UB LB UB LB UB p-Value Post Hoc

MIS post-IMMRP 2205 4.37 1.61 4.31 4.44 7938 0.33 1.08 0.30 0.35 4523 −2.74 1.16 −2.78 −2.71 <0.001 all different
diff-NRS-7days 2086 3.04 2.05 2.95 3.13 7511 1.01 1.69 0.97 1.04 4267 −0.28 1.58 −0.32 −0.23 <0.001 all different
diff-HADS-A 2191 5.12 3.72 4.96 5.28 7873 1.59 3.08 1.52 1.66 4458 −1.30 3.24 −1.39 −1.20 <0.001 all different
diff-HADS-D 2188 5.93 3.55 5.78 6.08 7869 2.24 2.95 2.17 2.30 4462 −0.96 3.04 −1.05 −0.87 <0.001 all different
diff-MPI-Pain-severity 2185 1.77 1.02 1.73 1.82 7874 0.56 0.74 0.54 0.58 4500 −0.17 0.69 −0.19 −0.15 <0.001 all different
diff-MPI-Pain-interfer 2173 1.53 0.99 1.49 1.57 7811 0.50 0.70 0.48 0.51 4453 −0.17 0.66 −0.18 −0.15 <0.001 all different
diff-MPI-LideCon 2189 1.94 1.05 1.89 1.98 7861 0.71 0.96 0.69 0.73 4491 −0.33 0.99 −0.36 −0.30 <0.001 all different
diff-MPI-distress 2187 2.18 1.17 2.13 2.23 7869 0.71 1.02 0.69 0.73 4487 −0.46 1.05 −0.49 −0.43 <0.001 all different
diff-MPI-SOCsupp 2180 −0.34 1.12 −0.39 −0.30 7828 −0.24 0.98 −0.26 −0.21 4462 −0.11 0.98 −0.14 −0.08 <0.001 all different
diff-MPI-punish 1991 0.39 1.20 0.34 0.45 7016 0.04 1.12 0.02 0.07 4008 −0.20 1.15 −0.24 −0.17 <0.001 all different
diff-MPI-protect 1988 −0.18 1.17 −0.23 −0.13 6984 −0.14 1.00 −0.17 −0.12 3989 −0.05 1.05 −0.09 −0.02 <0.001 cl1 NE cl2, cl2 NE cl3
diff-MPI-distract 1992 0.11 1.10 0.06 0.16 7012 0.00 0.96 −0.03 0.02 4006 0.01 1.03 −0.02 0.04 <0.001 cl1 NE cl2, cl3
diff-MPI-GAI 2187 0.57 0.82 0.53 0.60 7866 0.23 0.68 0.21 0.24 4489 −0.06 0.69 −0.08 −0.03 <0.001 all different
diff-EQ-5D-index 2105 0.44 0.30 0.43 0.45 7494 0.16 0.28 0.15 0.17 4205 −0.07 0.28 −0.08 −0.06 <0.001 all different
188
diff-EQ-VAS 2068 30.51 19.66 29.66 31.36 7409 11.61 18.58 11.19 12.03 4126 −3.84 19.15 −4.42 −3.25 <0.001 all different
diff-sf36-pf 2147 18.74 16.97 18.02 19.46 7644 6.02 13.63 5.72 6.33 4324 −3.83 14.22 −4.25 −3.40 <0.001 all different
diff-sf36-rp 2110 39.93 39.28 38.25 41.60 7513 10.46 29.70 9.79 11.13 4215 −5.96 25.56 −6.74 −5.19 <0.001 all different
diff-sf36-bp 2146 28.04 16.27 27.35 28.73 7663 9.72 12.96 9.43 10.01 4323 −2.93 12.38 −3.30 −2.56 <0.001 all different
diff-sf36-gh 2126 21.06 17.59 20.31 21.81 7529 6.05 14.51 5.72 6.37 4235 −4.89 14.57 −5.33 −4.45 <0.001 all different
diff-sf36-vt 2139 37.45 18.74 36.65 38.24 7626 13.58 17.26 13.19 13.96 4311 −4.20 16.16 −4.69 −3.72 <0.001 all different
diff-sf36-sf 2146 34.26 22.17 33.32 35.20 7652 10.12 20.39 9.66 10.58 4324 −9.86 21.10 −10.49 −9.23 <0.001 all different
diff-sf36-re 2087 43.52 44.58 41.60 45.43 7390 11.98 43.21 11.00 12.97 4121 −15.81 42.02 −17.09 −14.52 <0.001 all different
diff-sf36-mh 2139 29.61 17.48 28.86 30.35 7620 10.12 14.90 9.78 10.45 4307 −8.01 15.89 −8.49 −7.54 <0.001 all different
Change-Pain 2059 3.28 0.69 3.25 3.31 7280 2.53 0.87 2.51 2.55 4015 2.08 0.93 2.05 2.11 <0.001 all different
Change-Life situation 2067 3.51 0.58 3.48 3.53 7315 3.07 0.63 3.05 3.08 4032 2.76 0.72 2.74 2.79 <0.001 all different
LB = Lower Bound; UB = Upper Bound; diff = change in a certain variable; NRS-7days = Pain intensity as measured by a numeric rating scale for the previous seven days; HADS =
Hospital Anxiety and Depression Scale; MPI = Multidimensional Pain Inventory; EQ-5D-index = The index of the European quality of life instrument; EQ-VAS = The European quality of
life instrument thermometer-like scale; sf36 = The Short Form (36) Health Survey. For explanations of the subscale abbreviations, see Methods.
Table 7. Clusters from HCA based on MIS (t-scores) of the first component of the PCA for the changes in outcomes from pre-IMMRP to 12-month FU (denoted as
MIS 12-m FU). To facilitate understanding, the changes for all the outcomes are shown (mean, SD, and 95% confidence interval). The two bottom rows show the
estimations of changes (not included in PCA and the calculation of MIS).
Cluster 1 (12.4%) Cluster 2 (46.6%) Cluster 3 (41.0%)

95% 95% 95%
N Mean SD N Mean SD N Mean SD ANOVA
CI CI CI
J. Clin. Med. 2019, 8, 905

MIS -12-m FU 1099 5.01 1.78 4.90 5.11 4123 0.78 1.35 0.74 0.82 3629 −2.43 1.39 −2.47 −2.38 <0.001 all different
diff-NRS-7days 1031 3.67 2.15 3.54 3.80 3876 1.46 1.89 1.40 1.52 3435 −0.16 1.66 −0.21 −0.10 <0.001 all different
diff-HADS-A 1095 5.72 3.84 5.49 5.95 4087 2.06 3.34 1.96 2.16 3588 −0.80 3.53 −0.91 −0.68 <0.001 all different
diff-HADS-D 1096 6.13 3.75 5.90 6.35 4086 2.39 3.13 2.29 2.48 3588 −1.05 3.39 −1.16 −0.94 <0.001 all different
diff-MPI-Pain-severity 1092 2.30 1.14 2.24 2.37 4108 0.88 0.90 0.85 0.91 3619 −0.09 0.76 −0.12 −0.07 <0.001 all different
diff-MPI-Pain-interfer 1092 2.30 1.14 2.24 2.37 4108 0.88 0.90 0.85 0.91 3589 −0.14 0.74 −0.17 −0.12 <0.001 all different
diff-MPI-LifeCon 1086 2.27 1.10 2.21 2.34 4076 0.83 0.85 0.81 0.86 3604 −0.25 1.05 −0.28 −0.21 <0.001 all different
diff-MPI-distress 1091 2.10 1.10 2.03 2.16 4095 0.75 1.00 0.71 0.78 3618 −0.38 1.13 −0.41 −0.34 <0.001 all different
diff-MPI-SOCsupp 1086 −0.69 1.25 −0.77 −0.62 4081 −0.60 1.16 −0.64 −0.57 3583 −0.10 1.04 −0.13 −0.07 <0.001 all different
diff-MPI-punish 979 0.57 1.19 0.50 0.65 3633 −0.02 1.22 −0.06 0.02 3194 −0.13 1.22 −0.18 −0.09 <0.001 all different
diff-MPI-protect 980 −0.23 1.24 −0.31 −0.15 3616 −0.35 1.20 −0.39 −0.31 3173 0.03 1.09 −0.01 0.06 <0.001 all different
diff-MPI-distract 981 0.02 1.15 −0.05 0.10 3627 −0.22 1.09 −0.25 −0.18 3188 0.08 1.02 0.04 0.11 <0.001 CL NE cl3, cl2 NE cl3
diff-MPI-GAI 1090 0.76 0.95 0.70 0.82 4094 0.26 0.73 0.23 0.28 3613 −0.11 0.73 −0.14 −0.09 <0.001 all different
diff-EQ-5D-index 1048 0.53 0.30 0.51 0.55 3886 0.25 0.30 0.24 0.26 3351 −0.04 0.30 −0.05 −0.03 <0.001 all different
189
diff-EQ-VAS 1022 36.06 20.47 34.80 37.32 3833 16.27 19.82 15.64 16.89 3316 −3.31 19.66 −3.98 −2.64 <0.001 all different
diff-sf36-pf 1054 26.77 19.09 25.61 27.92 3953 10.00 15.13 9.53 10.47 3445 −3.31 15.24 −3.81 −2.80 <0.001 all different
diff-sf36-rp 1043 57.34 39.51 54.94 59.74 3889 19.15 34.30 18.07 20.22 3365 −3.69 27.14 −4.60 −2.77 <0.001 all different
diff-sf36-bp 1054 37.44 19.56 36.26 38.63 3954 14.29 14.79 13.83 14.75 3444 −1.33 13.03 −1.76 −0.89 <0.001 all different
diff-sf36-gh 1044 25.26 19.09 24.10 26.42 3908 7.78 16.33 7.26 8.29 3388 −5.04 15.87 −5.57 −4.50 <0.001 all different
diff-sf36-vt 1054 40.71 19.72 39.52 41.91 3951 13.32 17.83 12.77 13.88 3433 −4.60 16.67 −5.16 −4.05 <0.001 all different
diff-sf36-sf 1053 40.73 23.26 39.32 42.14 3958 14.43 21.21 13.77 15.09 3445 −7.66 22.38 −8.40 −6.91 <0.001 all different
diff-sf36-re 1031 53.10 44.27 50.40 55.81 3849 17.22 45.08 15.79 18.64 3277 −9.79 45.59 11.35 −8.22 <0.001 all different
diff-sf36-mh 1054 32.77 18.81 31.64 33.91 3948 10.62 16.33 10.11 11.13 3430 −6.66 17.25 −7.24 −6.09 <0.001 all different
Change-Pain 1049 3.32 0.74 3.28 3.37 3887 2.72 0.81 2.69 2.75 3373 2.20 0.85 2.17 2.22 <0.001 all different
Change-Life situation 1049 3.52 0.64 3.48 3.56 3901 3.05 0.70 3.03 3.08 3375 2.62 0.83 2.59 2.65 <0.001 all different
LB = Lower Bound; UB = Upper Bound; diff = change in a certain variable; NRS-7days = Pain intensity as measured by a numeric rating scale for the previous seven days; HADS =
Hospital Anxiety and Depression Scale; MPI = Multidimensional Pain Inventory; EQ-5D-index = The index of the European quality of life instrument; EQ-VAS = The European quality of
life instrument thermometer-like scale; sf36 = The Short Form (36) Health Survey. For explanations of the subscale abbreviations, see Methods.
Table 8. Pre-IMMRP values for the three clusters based on MIS obtained post-IMMRP.
Cluster 1 Cluster 2 Cluster 3

95% 95% 95%
Baseline N Mean SD N Mean SD N Mean SD ANOVA
CI CI CI
Gender 2205 0.22 0.41 0.20 0.23 7938 0.24 0.43 0.23 0.25 4523 0.25 0.43 0.24 0.26 0.014 NA
J. Clin. Med. 2019, 8, 905
Age 2205 42.7 11.2 42.2 43.2 7938 43.5 10.7 43.3 43.8 4523 43.0 10.6 42.7 43.3 0.001 cl1 NE cl3, cl2 NE cl3
Outside-Europe 2185 0.11 0.31 0.09 0.12 7877 0.10 0.30 0.09 0.10 4484 0.11 0.32 0.10 0.12 0.011 NA
University 2168 0.28 0.45 0.26 0.29 7826 0.26 0.44 0.25 0.27 4445 0.23 0.42 0.22 0.24 0.000 cl1 NE cl2, cl2 NE cl3
Days no work 716 889 2912 675 1102 2976 1037 2311 954 1120 1774 1152 2502 1036 1269 0.045 NA
PRI 2205 13.8 8.3 13.4 14.1 7938 14.4 8.3 14.2 14.6 4523 14.5 8.3 14.3 14.7 0.002 NA
NRS-7days 2158 7.1 1.7 7.0 7.2 7801 6.9 1.7 6.8 6.9 4440 6.7 1.7 6.7 6.8 0.000 all different
HADS-A 2199 10.4 4.7 10.2 10.6 7891 9.0 4.7 8.9 9.1 4494 8.2 4.6 8.1 8.4 0.000 all different
HADS-D 2197 9.6 4.4 9.4 9.8 7892 8.6 4.4 8.5 8.7 4494 7.7 4.3 7.6 7.9 0.000 all different
MPI-Pain-severity 2193 4.5 0.9 4.5 4.6 7895 4.4 0.9 4.4 4.4 4510 4.3 0.9 4.3 4.3 0.000 all different
MPI-Pain-interfer 2187 4.6 1.0 4.6 4.6 7853 4.4 1.0 4.4 4.4 4485 4.3 1.0 4.2 4.3 0.000 all different
MPI-LifeCon 2195 2.4 1.1 2.4 2.5 7880 2.7 1.1 2.7 2.7 4502 2.9 1.1 2.9 3.0 0.000 all different
MPI-Distress 2191 3.9 1.2 3.9 4.0 7891 3.5 1.3 3.5 3.5 4502 3.2 1.3 3.1 3.2 0.000 all different
MPI-Socsupp 2190 4.2 1.4 4.2 4.3 7861 4.2 1.3 4.1 4.2 4488 4.1 1.4 4.1 4.2 0.005 NA
MPI-punish 2069 1.9 1.5 1.8 1.9 7319 1.8 1.4 1.7 1.8 4169 1.7 1.3 1.6 1.7 0.000 all different
MPI-protect 2065 3.0 1.5 2.9 3.1 7295 2.9 1.4 2.9 3.0 4158 3.0 1.4 2.9 3.0 0.136 NA
MPI-distract 2069 2.6 1.2 2.5 2.6 7312 2.5 1.2 2.5 2.5 4168 2.5 1.2 2.5 2.6 0.075 NA
190
MPI-GAI 2193 2.4 0.8 2.4 2.4 7885 2.4 0.8 2.4 2.5 4500 2.5 0.8 2.5 2.5 0.000 cl1 NE cl2, cl2 NE cl3
EQ-5D-index 2126 0.2 0.3 0.2 0.2 7587 0.3 0.3 0.2 0.3 4277 0.3 0.3 0.3 0.3 0.000 all different
EQ-VAS 2097 38.0 18.2 37.2 38.8 7529 40.7 19.0 40.3 41.1 4224 43.9 19.4 43.3 44.5 0.000 all different
sf36-pf 2151 52.1 21.0 51.2 52.9 7683 52.8 20.6 52.3 53.2 4349 53.2 20.2 52.6 53.8 0.119 NA
sf36-rp 2139 9.0 19.8 8.2 9.9 7629 11.8 23.8 11.3 12.4 4283 15.3 26.8 14.5 16.1 0.000 all different
sf36-bp 2151 21.1 13.8 20.5 21.7 7694 24.1 14.3 23.8 24.4 4347 26.4 14.6 26.0 26.8 0.000 all different
sf36-gh 2139 39.8 20.0 38.9 40.6 7610 41.4 20.1 41.0 41.9 4299 43.3 20.4 42.7 43.9 0.000 all different
sf36-vt 2151 19.7 16.6 19.0 20.4 7679 23.3 18.4 22.9 23.7 4347 27.3 19.0 26.7 27.8 0.000 all different
sf36-sf 2151 40.0 23.7 39.0 41.0 7690 46.6 24.9 46.1 47.2 4348 52.1 25.3 51.4 52.9 0.000 all different
sf36-re 2126 30.6 39.6 28.9 32.2 7549 41.6 42.6 40.7 42.6 4220 50.6 43.6 49.3 51.9 0.000 all different
sf36-mh 2151 47.3 20.7 46.5 48.2 7672 54.5 21.2 54.0 54.9 4343 60.1 20.5 59.4 60.7 0.000 all different
LB = Lower Bound; UB = Upper Bound; NA = not applicable; NRS-7days = Pain intensity as measured by a numeric rating scale for the previous seven days; HADS = Hospital Anxiety
and Depression Scale; MPI = Multidimensional Pain Inventory; EQ-5D-index = The index of the European quality of life instrument; EQ-VAS = The European quality of life instrument
thermometer-like scale; sf36 = The Short Form (36) Health Survey; PRI = Pain Region Index. For explanations of the subscale abbreviations, see Methods.
Table 9. Pre-IMMRP values for the three clusters based on MIS obtained at 12-month FU.
Cluster 1 Cluster 2 Cluster 3

95% 95% 95%
Baseline N Mean SD N Mean SD N Mean SD ANOVA
CI CI CI
Gender 1099 0.24 0.43 0.21 0.26 4123 0.21 0.41 0.20 0.22 3629 0.25 0.43 0.24 0.27 <0.001 all different
J. Clin. Med. 2019, 8, 905
Age 1099 41.9 11.1 41.2 42.5 4123 43.7 11.1 43.4 44.0 3629 44.2 10.4 43.8 44.5 <0.001 all different
Outside-Europe 1088 0.09 0.29 0.07 0.11 4091 0.08 0.28 0.08 0.09 3606 0.10 0.30 0.09 0.11 0.012 NA
University 1079 0.29 0.45 0.26 0.31 4060 0.27 0.45 0.26 0.29 3567 0.23 0.42 0.21 0.24 <0.001 all different except cl2 vs. cl3
Days no work 358 661 2587 392 930 1409 1046 2339 923 1168 1323 1270 2604 1130 1411 <0.001 all different
PRI 1099 12.8 8.0 12.3 13.2 4123 14.2 8.3 14.0 14.5 3629 14.8 8.3 14.5 15.1 <0.001 all different
NRS-7days 1071 7.0 1.7 6.9 7.1 4049 6.8 1.7 6.8 6.9 3574 6.8 1.7 6.8 6.9 0.049 NA
HADS-A 1096 9.7 4.7 9.4 10.0 4101 8.7 4.7 8.6 8.9 3606 8.4 4.6 8.3 8.6 <0.001 all different
HADS-D 1096 8.8 4.4 8.6 9.1 4102 8.2 4.3 8.1 8.3 3606 8.0 4.4 7.9 8.1 <0.001 all different
MPI-Pain-severity 1094 4.5 0.9 4.4 4.5 4114 4.4 0.9 4.3 4.4 3625 4.3 0.9 4.3 4.4 <0.001 cl1NE cl2, cl2 NE cl1, cl3
MPI-Pain-interfer 1093 4.5 0.9 4.5 4.6 4101 4.4 1.0 4.3 4.4 3609 4.3 1.0 4.2 4.3 <0.001 all different
MPI-LifeCon 1096 2.5 1.1 2.5 2.6 4113 2.8 1.1 2.7 2.8 3614 2.9 1.1 2.8 2.9 <0.001 all different
MPI-Distress 1095 3.8 1.2 3.8 3.9 4114 3.4 1.3 3.4 3.5 3621 3.3 1.3 3.2 3.3 <0.001 all different
MPI-Socsupp 1090 4.3 1.3 4.2 4.4 4097 4.2 1.3 4.2 4.3 3604 4.1 1.4 4.1 4.1 <0.001 all different
MPI-punish 1036 1.8 1.4 1.7 1.9 3833 1.7 1.3 1.6 1.7 3355 1.7 1.3 1.7 1.8 0.047 NA
IMP-protect 1038 3.0 1.4 2.9 3.1 3824 2.9 1.4 2.9 3.0 3341 2.9 1.4 2.9 3.0 0.583 NA
MPI-distract 1039 2.6 1.2 2.5 2.6 3831 2.6 1.2 2.5 2.6 3352 2.5 1.2 2.4 2.5 0.003 NA
191
MPI -GAI 1094 2.4 0.9 2.4 2.5 4108 2.5 0.8 2.5 2.5 3623 2.5 0.8 2.5 2.5 0.071 NA
EQ-5D-index 1058 0.2 0.3 0.2 0.2 3935 0.3 0.3 0.3 0.3 3407 0.3 0.3 0.3 0.3 <0.001 all different
EQ-VAS 1037 39.2 18.2 38.1 40.3 3905 41.3 19.2 40.7 42.0 3389 43.1 19.6 42.4 43.7 <0.001 all different
sf36-pf 1056 51.9 20.4 50.7 53.1 3969 53.0 20.4 52.4 53.7 3459 53.4 20.1 52.7 54.1 0.120 NA
sf36-rp 1053 8.5 20.6 7.2 9.7 3938 12.4 24.1 11.6 13.1 3417 15.3 26.9 14.4 16.2 <0.001 all different
sf36-bp 1058 21.5 13.3 20.7 22.3 3974 24.4 14.2 23.9 24.8 3461 25.9 14.0 25.4 26.3 <0.001 all different
sf36-gh 1052 43.1 21.0 41.8 44.4 3944 42.6 20.5 42.0 43.2 3424 42.3 20.3 41.7 43.0 0.556 NA
sf36-vt 1058 21.4 17.8 20.3 22.5 3972 24.7 19.1 24.1 25.3 3452 26.3 18.6 25.7 26.9 <0.001 all different
sf36-sf 1056 42.4 24.2 40.9 43.9 3976 48.2 25.6 47.4 49.0 3458 51.9 25.2 51.0 52.7 <0.001 all different
sf36-re 1046 32.1 40.3 29.7 34.5 3906 44.0 43.2 42.7 45.4 3363 49.1 43.2 47.6 50.5 <0.001 all different
sf36-mh 1058 49.6 20.9 48.3 50.9 3970 56.0 21.0 55.3 56.7 3451 58.7 20.9 58.0 59.4 <0.001 all different
LB = Lower Bound; UB = Upper Bound; NA = not applicable; NRS-7days = Pain intensity as measured by a numeric rating scale for the previous seven days; HADS = Hospital Anxiety
and Depression Scale; MPI = Multidimensional Pain Inventory; EQ-5D-index = The index of the European quality of life instrument; EQ-VAS = The European quality of life instrument
thermometer-like scale; sf36 = The Short Form (36) Health Survey; PRI = Pain Region Index. For explanations of the subscale abbreviations, see Methods.
J. Clin. Med. 2019, 8, 905
3.7. Longitudinal Regression of MIS Using Baseline Data

The outcome data at baseline (pre-IMMRP) together with the background variables were used
to regress MIS-post-IMMRP and MIS-12-month FU (Table 10). For both MIS, psychological distress
variables were the most important regressors, but life impact variables, pain aspects, and health and
vitality aspects contributed significantly. The directions of the correlations revealed that a more severe
clinical situation (e.g., psychological distress, lack of control, low vitality and health, pain interference,
and high pain intensity) were associated with high MIS (i.e., multivariate improvements). Although
the obtained regressions were highly significant according to the CV-ANOVA, the explained variations
in MIS were less than 10% (R2 = 0.08 in both analyses). Hence, most of the variations in the two MIS
were not possible to predict.
Similar analyses for each of the clusters (Supplementary Tables S2 and S3) revealed that regressions
were highly significant, but only explained a minority of the variations in MIS. Although the relative
importance of the variables pre-IMMRP differed somewhat between the three clusters, no marked
differences existed; that is, psychological distress aspects were the most important post-IMMRP
(Supplementary Table S2). For the 12-month FU, somewhat more pronounced differences existed
between the clusters: in cluster 2, the pain intensity aspects were the most important for MIS, and in
cluster 1 and cluster 3, psychological distress variables together with pain interference were the most
important for MIS.
Table 10. Orthogonal Partial Least Square Regressions (OPLS) regressions of MIS post-IMMRP (left part)
and at 12-month FU (right part) using the variables pre-IMMRP as regressors. Variables in bold type
are significant regressors.
VIP p(corr) VIP p(corr)
Variables Pre-IMMRP Variables Pre-IMMRP
sf36-mh 1.80 −0.80 sf36-mh 1.63 −0.62
MPI-Distress 1.72 0.76 MPI-Distress 1.59 0.61
HADS-D 1.56 0.68 sf36-sf 1.44 −0.53
MPI-LifeCon 1.48 −0.65 sf36-re 1.39 −0.54
HADS-A 1.48 0.65 MPI-LifeCon 1.35 −0.49
sf36-sf 1.47 −0.63 HADS-D 1.34 0.46
sf36-re 1.43 −0.64 HADS-A 1.28 0.46
sf36-vt 1.27 −0.54 MPI-Pain-interfer 1.26 0.39
MPI-Pain-interfer 1.26 0.45 Persistent-Pain-duration 1.16 −0.46
EQ-5D-index 1.12 −0.41 Pain duration 1.15 −0.45
sf36-bp 1.07 −0.35 EQ-5D-index 1.14 −0.37
MPI-Pain-severity 1.05 0.28 sf36-bp 1.11 −0.35
EQ-VAS 1.04 −0.39 sf36-vt 1.11 −0.36
sf36-gh 0.95 −0.30 MPI-Pain-severity 0.99 0.21
NRS-7days 0.88 0.20 EQ-VAS 0.97 −0.28
sf36-pf 0.87 −0.07 sf36-rp 0.96 −0.37
sf36-rp 0.80 −0.33 PRI 0.95 −0.26
PRI 0.72 −0.09 sf36-gh 0.87 −0.10
MPI-GAI 0.68 −0.20 NRS-7days 0.81 0.11
MPI-punish 0.59 0.25 Days no work 0.80 -0.31
Outside-Europe 0.45 −0.01 sf36-pf 0.76 −0.05
Days no work 0.44 −0.16 Age 0.75 −0.30
University 0.43 0.12 MPI-GAI 0.72 −0.22
Persistent Pain duration 0.42 −0.16 University 0.54 0.18
MPI-protect 0.41 −0.04 MPI-punish 0.43 0.12
Pain duration 0.38 −0.15 Outside-Europe 0.39 −0.03
MPI-Socsupp 0.32 −0.05 MPI-protect 0.31 0.03
MPI-distract 0.29 −0.01 MPI-distract 0.26 0.06
Age 0.23 −0.10 MPI-Socsupp 0.22 0.07
Gender 0.04 −0.01 Gender 0.10 −0.04
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Table 10. Cont.
VIP p(corr) VIP p(corr)
Variables Pre-IMMRP Variables Pre-IMMRP
R2 0.08 R2 0.08
Q2 0.08 Q2 0.07
n 14 657 n 7 976
CV-ANOVA p-value <0.001 CV-ANOVA p-value <0.001
VIP (VIP > 1.0 is significant) and p (corr) are reported for each regressor. The sign of p (corr) indicates the direction
of the correlation with the dependent variable (+ = positive correlation; − = negative correlation). The four bottom
rows of each regression report R2 , Q2 , and p-value of the CV-ANOVA and number of patients included in the
regression (n). NRS-7days = Pain intensity as measured by a numeric rating scale for the previous seven days;
HADS = Hospital Anxiety and Depression Scale; MPI = Multidimensional Pain Inventory EQ-5D-index = The index
of the European quality of life instrument; EQ-VAS = The European quality of life instrument thermometer-like scale;
sf36 = The Short Form (36) Health Survey; PRI = Pain Region Index. For explanations of the subscale abbreviations
see Methods.
4. Discussions
The major findings of the present large PROM study from SQRP are listed below:
• Moderate long-term ES were found for pain intensity (MPI Pain severity and SF-36 bodily pain),
interference in daily life (MPI Interference), and state of health (EQ-5D-index); most other variables
showed small ES. Vitality also displayed moderate effect sizes immediately after IMMRP but
fell slightly under cut-off for moderate change at 12-month follow-up. The majority of the 22
investigated outcomes were significantly improved.
• Significant intercorrelations between changes in pain intensity, interference, control, psychological
distress, and mental health were confirmed. The changes in 22 outcomes reflected one (pre-IMMRP
versus post-IMMRP) or three (pre-IMMRP versus 12-month follow-up) latent components (groups
of variables).
• The outcomes were best for patients with the worst self-reported clinical presentation pre-IMMRP.
Based on a defined multivariate improvement score (MIS), three clusters were identified. Cluster
1—overall, the worst situation pre-IMMRP—showed positive multivariate improvements in
outcomes. Cluster 3—deteriorated—showed negative scores. Cluster 2, the intermediate cluster,
was associated with overall slightly positive multivariate improvements.
• Certain variables (especially psychological distress and life impact variables, pain, and health
and vitality aspects) pre-IMMRP were associated with improvements according to MIS both
post-IMMRP and at 12-month FU. However statistically significant, the pre-IMMRP situation
could only explain a small part of the variation in MIS (8%); therefore, for clinical use, it was not
possible to predict those who would benefit most from IMMRP.
The outcome variables mandatory in SQRP and presented in the present study are in good
agreement with the BSP model of chronic pain and the outcome domains presented by the Initiative on
Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT) [7,52] and the Validation
and Application of a patient-relevant core set of outcome domains to assess multimodal PAIN therapy
(VAPAIN) [14] initiatives.
The present study was not primarily designed to evaluate the efficacy of IMMRP, which requires
RCTs and SRs/meta-analyses. However, our results for the repeated measurements (Tables 2 and 3)
of chronic pain patients in real-life practice settings are in agreement with the positive evidence for
IMMRPs reported in SRs [10–12] and in other studies [22,23,53]. As such, the small to moderate
ES are noteworthy as these patients, who receive pain rehabilitation in specialist care centres, often
have tried other treatments for their chronic pain with no or little effect. That is, these patients
have severe problems and relative treatment resistance. Interestingly, the changes in outcomes with
moderate ES are broad and not limited to a single outcome domain, and the most stable moderate ES
were demonstrated for pain intensity aspects with moderate improvement both immediately after
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J. Clin. Med. 2019, 8, 905
IMMRPs and at 12-month follow-up. Pain interference demonstrated moderate ES improvement at

12-month follow-up, and vitality was moderately improved immediately after IMMRPs. Both objective
registrations (e.g., sick-leave registrations and actigraphic recordings [54]) and subjective PROM data
may be important for understanding the efficacy of IMMRPs. Very recently, a SQRP study using a
subgroup of the same cohort of patients reported that sick leave benefits according to the Swedish
Social Insurance Agency decreased as a consequence of IMMRP [55]. Hence, both PROM data and
objective sick leave data indicate clinically important positive changes in response to IMMRPs for
patients in real-life practice settings. As a comparison, SRs conclude that common pharmacological
treatments—e.g., paracetamol, non-steroidal anti-inflammatory drugs, and opioids—for patients with
chronic pain have no effects, small effects, and/or lack of long-term follow-up effects [56–58].
The present study reported medium ES for two of three pain intensity variables both post-IMMRP
and at 12-month FU (i.e., for MPI-pain-severity and sf36-bp); the third pain intensity variable had effect
sizes near medium ES. These results contrasted some SRs reporting of no evidence for efficacy with
respect to pain intensity [10,11]. However, not all RCTs of IMMRP included pain intensity outcomes,
since the interventions are not focused on the pain itself but rather on its consequences [10,11].
Obviously, many pain patients consider pain intensity improvement to be the most important aspect
of treatments [59]. However, changing this perspective is considered important in IMMPRs, since
focusing on pain reduction in many cases leads to short-sighted attempts to control pain, and this
may, when not successful, lead to increased physical and psychological disability and reduced life
quality [60,61]. Thus, specialist care IMMRPs in Sweden have largely adopted the idea of introducing
acceptance as a cornerstone of the psychological component of IMMRP (i.e., the willingness to have
the experiences of pain as it is and to encourage patients to set up activity-related rehabilitation goals
and risk initial pain flare-ups). This also means that patients are advised against establishing pain
reduction goals. Thus, it could be considered problematic to communicate the present results showing
medium effect sizes in real-world practice settings on pain. On the other hand, it may also be ethically
problematic if both clinical practice and research ignore the reports and wishes of the patients regarding
pain intensity. However, health care providers should not underestimate their patients’ ability to grasp,
once explained, the complex pain experience. Therefore, health care providers should emphasise pain
education, including descriptions of the affective and cognitive elements of pain as rational for the
different components of IMMRPs, and stress the need to experiment with new behaviours and risk
short-term pain flare-ups. Since the results are obtained in this context, no change in clinical practise as
far as pain communication is called for.
SRs of IMMRP report that it is an effective intervention with small to moderate effects for patients
with chronic pain conditions [11,12,62,63]. The present results concerning ES agree with most SRs
of IMMRP, but it may also be appropriate to compare with ES results reported in other clinical
studies. The moderate ES for two of the pain intensity variables agree with studies in clinical routine
care (n = 65–395), and therefore, for long-term follow-up (6–12 months), such studies report small
(Cohen’s d: 0.20–0.33 [64,65]) to moderate (Cohen’s d: 0.59–0.70 [26,66,67]) ES for pain intensity. For
psychological distress variables, these studies agree with the present results: they generally found small
ES for long-term follow-up (i.e., Cohen’s d = 0–0.38 for depressive symptoms [26,64,65] and Cohen’s
d = 0.22–0.34 for anxiety) [26,65]. In a recent RCT comparing transdiagnostic emotion-focused exposure
treatment (Hybrid) and Internet-delivered pain management treatment (ICBT) for chronic pain patients
with comorbid anxiety and depression, we found that within group ES pre versus follow-up for
pain interference were reported both for hybrid (ES = 1.17) and for ICBT (ES = 0.65) compared the
present effect size of 0.49 [68]. However, the patients were not exclusively recruited from specialist
care (i.e., clinical departments of pain rehabilitation); they were also recruited via advertisements
in local newspapers and social media [68], and the numbers investigated were considerably smaller.
An important observation from the present study is that moderate ES found at 12-month follow-up
covered broad aspects (e.g., pain intensity, interference in daily life, and perceived health).
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J. Clin. Med. 2019, 8, 905
The number of outcomes in IMMRPs in RCTs are generally high, which reasonably reflects the
broad goals of the complex intervention. The present study used 22 outcomes that are mandatory in
SQRP measured on up to three occasions (i.e., pre-IMMRP, post-IMMRP, and 12-month follow-up).
PCA was applied to handle the pattern of changes in potentially intercorrelated outcomes as suggested
by the Medical Research Council of the United Kingdom [69]. From these analyses, it can be concluded
that changes in pain intensity, pain interference, psychological distress, vitality, etc. were positively
intercorrelated (Table 5). In fact, our study showed that the changes in the majority of the 22
outcomes are significantly intercorrelated. Hence, the changes in these variables cannot be considered
independent of each other. As a consequence of this observation, the appropriateness to evaluate
changes in outcomes separately, as done in a recent SR [70], must be questioned, since the treatment was
not designed to target only a single outcome. Moreover, the ES must be seen in this complex context.
Thus, small changes in many outcomes may be more important than one prominent change in a single
or few outcomes. Furthermore, the Grading of Recommendations Assessment, Development and
Evaluation (GRADE) used for evidence ratings in SRs may not adequately describe the evidence base
of complex interventions [71]. Different definitions of positive outcomes of IMMRP interventions exist
(e.g., the majority of outcomes had to be significantly better than for the control intervention) [10,11].
Another approach was that the authors of the SR predetermined primary and secondary outcomes and
what was necessary to classify an intervention as positive before reviewing the RCTs [12].
The presented PCAs also highlight that it may be possible to reduce the number of outcome
variables, since several of these appear to measure similar aspects of the chronic pain condition. The
fact that 22 outcomes were analysed (Tables 2 and 3) may raise an issue of multiple comparisons. In
such situations, Bonferroni corrections are frequently used [72,73]. This is a conservative approach
when the number of tests increases [72,74,75], the chances to detect real treatment effects decrease, and
corrections were designed for corrections of independent comparisons [74]. The latter is obviously not
present for most changes in outcome variables according to the PCAs performed (Table 5). Hierarchal
or ‘gatekeeping’ procedures do not require adjustment for multiplicity [73], but require a natural
hierarchy of the outcomes, as such a hierarchy is not obvious for IMMRP, as discussed above. Another
approach is that outcomes are combined into a single composite outcome (i.e., a composite outcome
consists of two or more component outcomes) [76], but this may be problematic with respect to
missing cases and when the components of the composite endpoint are measured on different scales
(i.e., non-commensurate outcomes) [76]. However, some multivariate methods such as PCA and
OPLS can handle non-commensurate outcomes [76]. We used advanced PCA, including the NIPALS
algorithm, to handling missing data and non-commensurate outcomes. We calculated the t-scores for
the most relevant latent factor (component). Hence, we defined an objective Multivariate Improvement
Score (MIS; the t-score of the first PCA component), which on an individual patient level defines the
multivariate improvement; a positive MIS indicates multivariate improvements because of IMMRP.
Three clearly separated clusters based on MIS were identified. On a group level, clusters 1 and
2 were associated with various degrees of improvements, whereas cluster 3 showed negative MIS,
indicating deterioration. Although the greater improvement in cluster 1 can be interpreted as a sign
of regression to the mean and that these patients did not benefit from IMMRP more than cluster 2,
this cluster still improves from IMMRP at least as well as those with e.g., less severe psychological
distress symptoms (clusters 2 and 3). This may seem unexpected, but it is important to recognise
that addressing psychological symptoms with CBT is an important component of IMMRPs. The
patients at post-IMMRP and 12-month follow-up estimated the degree of positive change in pain
(i.e., Change-pain) and the ability to handle life situation in general (i.e., Change-life situation).
Most patients reported improvements according to both the Change-pain and Change-life situations
(Table 4). Relatively small proportions of the patients reported worse situations post-IMMRP and at
the 12-month follow-up, which are results that agree with other studies [29,77,78]. These two variables
have retrospective elements even though they are not explicitly expressed. There are several problems
with such items in general—e.g., desirability and memory aspects, recall time [79–81], and in treatment
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context (e.g., overly optimistic assessments) [82]. However, on a general level, these estimations and
the two MIS variables (Tables 6 and 7) agreed.
We found that cluster 1, which had high MIS values (i.e., prominent improvements), had a more
severe clinical picture at baseline/pre-IMMRP than those with lower MIS (i.e., less improvements).
These results agree with another SQRP study (N > 35,000) that identified clusters based on the
clinical presentation at assessment (decision not taken about participation in IMMRP); the study found
that patients with the most severe clinical situation who later participated in IMMRP had the most
prominent improvements in six investigated outcomes [34]. Although IMMRP has been commended
for its effectiveness (‘of all approaches to the treatment of chronic pain, none has a stronger evidence
basis for efficacy, cost-effectiveness, and lack of iatrogenic complications’) [83], both this and our recent
study [34] indicate that not all patients show important improvements in several domains of outcome
after IMMRP. Both this and our previous study identified a large subgroup of patients that do not
seem to significantly benefit from IMMRP. Presumably, these patients—in the present study, those with
negative MIS (i.e., cluster 3)—need other interventions. In a relative context, they have a somewhat
less complicated self-reported clinical picture pre-IMMRP than those in clusters 1 and 2, even though
they are referred to specialist care and hence represent patients with complex needs.
The longitudinal regressions of MIS using background variables and pre-IMMRP data as regressors
were significant (Table 10). A blend of variables was important; psychological distress variables were
most important, but life impact variables, pain aspects, and health and vitality aspects contributed.
Our results appear to be in line with a recent meta-analysis on prognostic factors for IMMRP
outcome, demonstrating that both pre-treatment general emotional distress and pain-specific cognitive
behavioural factors are related to worse long-term (>6 months) physical functioning [84]. Unfortunately,
these regressions cannot be used clinically, since they only explained 8% of variations in MIS. Although
the prediction does not work clinically, this and a previous study from our group give clear indications
that patients with a severe clinical situation benefit from IMMRP [34].
4.1. Important Clinical Implications

Outcomes of IMMRP in real-life practice settings agree with the conclusions from SRs. Partly in
contrast to SRs, this registry study of patients managed within specialist care found that pain intensity
was positively affected because of IMMRP. It was also obvious that not all patients benefit from IMMRP.
Hence, there is a need to develop better matching between clinical presentation and participation in
MMRP in real-life practice settings. Moreover, the intercorrelations of most changes in outcomes also
opens up the possibility of reducing the number of outcome variables and hereby reduce the burden
upon patients included in the SQRP.
4.2. Strengths and Limitations

This study’s strengths include a large number of patients with complex chronic pain conditions
with a nation-wide representation. However, these patients were referred to specialist clinics and thus
represent a selection of the most difficult cases, so our results cannot be generalised to other settings.
Another strength was the use of MVDA methods such as PCA and OPLS to handle correlation patterns,
repeated measures, and regressions when there were obvious risks for multicollinearity. Changes in the
social context may have changed and influenced the longitudinal analyses; however, we used validated
and well-known instruments. Repeated evaluations using PROM questionnaires in treatment studies
may be problematic [85]. Thus, the changes that the patient undergo because of the intervention
(i.e., IMMRP) may affect the interpretations of the questions when presented at follow-up. The fact
that no control group or treatment-as-usual group was available, which ethically is complicated to
arrange for a registry of real-life practice patients, might have influenced our interpretation of changes
after IMMRP. Data for the time period 2008–2016 from the SQRP was used in the present study, and
changes in the content of IMMRP may have occurred. Unfortunately, no data concerning such changes
are available.
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J. Clin. Med. 2019, 8, 905
5. Conclusions
This large-scale study of IMMRPs in real life practise settings demonstrates significant outcome
changes in almost all measures. Most short-term and long-term effect sizes were small, but interestingly,
moderate long-term effect sizes were demonstrated for pain, pain interference in daily life, and
perceived health. In addition, patients reporting higher levels of perceived disability and suffering
displayed greater improvement.
Supplementary Materials: The following are available online at http://www.mdpi.com/2077-0383/8/6/905/s1,

Table S1: Pre-IMMRP situation for patients reporting their outcomes at 12-m FU and those not reporting their
outcomes at 12-m FU, Table S2: OPLS regressions of MIS at post IMMRP in the three clusters, Table S3: OPLS
regressions of MIS at 12-month FU in the three clusters.
Author Contributions: Conceptualization, Å.R., E.D., M.B., B.L. and B.G.; Data curation, Å.R. and B.G.; Formal
analysis, B.L. and B.G.; Methodology, Å.R., M.B. and B.G.; Validation, E.D.; Writing—original draft, B.G.;
Writing—review & editing, Å.R., E.D., M.B. and B.L. All authors commented on different versions of the
manuscript and all authors have approved the final version of the manuscript.
Funding: This study was supported by external funding from the Swedish Research Council (2018-02470), County
Council of Östergötland (forsknings-ALF; LIO-608021), and AFA insurance (140340). AFA Insurance, a commercial
founder, is owned by Sweden’s labour market parties: The Confederation of Swedish Enterprise, the Swedish
Trade Union Confederation (LO), and The Council for Negotiation and Co-operation (PTK). They insure employees
in the private sector, municipalities, and county councils. AFA Insurance does not seek to generate a profit,
which implies that no dividends are paid to shareholders. The sponsors of the study had no role in study design,
data collection, data analysis, data interpretation, writing of the report, or the decision to submit for publication.
The authors had full access to all the data in the study and had final responsibility for the decision to submit
for publication.
Acknowledgments: The authors are very grateful for valuable comments from Marcelo Rivano Fischer, PhD.
List of Abbreviations
ACT Acceptance Commitment Therapy
ANOVA Analysis of Variance
BPS biopsychosocial
CBT Cognitive Behavioral Therapy
Change-pain positive change in pain
Change-life situation change in ability to handle life situations in general
CI confidence interval
CV-ANOVA ANOVA of the cross-validated residuals
ES effect size
EQ-5D European Quality of Life instrument
EQ-5D-index index of EQ-5D based on five items
EQ-VAS health scale of EQ-5D
FU follow-up
GRADE Grading of Recommendations Assessment, Development and Evaluation
HADS Hospital Anxiety and Depression Scale
HADS-A Hospital Anxiety and Depression Scale—anxiety subscale
HADS-D Hospital Anxiety and Depression Scale—depression subscale
HCA Hierarchical Clustering Analysis
HR-QoL health-related quality of life
IASP the International Association for the Study of Pain
IMMPACT the Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials
IMMRP Interdisciplinary Multimodal Pain Rehabilitation Program
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J. Clin. Med. 2019, 8, 905
LR logistic regression
MIS Multivariate Improvement Score
MLR multiple linear regression
MPI Multidimensional Pain Inventory
MPI-Pain-severity MPI subscale concerning pain severity
MPI-Pain-interfer MPI subscale concerning pain-related interference
MPI-Distress MPI-SocSupp affective distress
MPI-LifeCon MPI subscale concerning life control
MPI-SocSupp MPI subscale concerning social support
MPI-Punish MPI subscale concerning punishing responses
MPI-Solict MPI subscale concerning solicitous responses
MPI-Distract MPI subscale concerning distracting responses
MPI-GAI MPI subscale General Activity Index
MVDA advanced multivariate analysis
NIPALS Non-linear Iterative Partial Least Squares
NRS Numeric Rating Scale
NRS-7days average pain intensity the last week
OPLS Orthogonal Partial Least Square Regression
Outside-Europe born outside Europe
PBE practice-based evidence
P(corr) loading scaled as a correlation coefficient between −1.0 and +1.0
PCA Principal Component Analysis
PLS-DA partial least square discriminant analysis
PRI Pain Region Index
PROM patient reported outcome measures
RCT Randomised Controlled Trial
SQRP Swedish Quality Registry for Pain Rehabilitation
sf36 Short Form Health Survey
sf36-pf sf36 subscale concerning physical functioning
sf36-rp sf36 subscale concerning role limitations due to physical functioning
sf36-bp sf36 subscale concerning bodily pain
sf36-gh sf36 subscale concerning general health
sf36-vt sf36 subscale concerning vitality
sf36-sf sf36 subscale concerning social functioning
sf36-re sf36 subscale concerning role limitations due to emotional problems
sf36-mh sf36 subscale concerning mental health
SR systematic review
University University education
Validation and Application of a patient-relevant core set of outcome domains to
VAPAIN
assess multimodal PAIN therapy
VIP variable influence on projection
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Journal of
Clinical Medicine
Article
Dissociation and Pain-Catastrophizing: Absorptive
Detachment as a Higher-Order Factor in Control of
Pain-Related Fearful Anticipations Prior to Total Knee
Arthroplasty (TKA)
Matthias Vogel 1, *,† , Martin Krippl 2,† , Lydia Frenzel 1 , Christian Riediger 3 , Jörg Frommer 1 ,
Christoph Lohmann 3 and Sebastian Illiger 3
1 Universitätsklinik für Psychosomatische Medizin und Psychotherapie der Otto-von-Guericke-Universität
Magdeburg, Leipziger Straße 44, 39120 Magdeburg, Germany; Lydia.frenzel@med.ovgu.de (L.F.);
joerg.frommer@med.ovgu.de (J.F.)
2 Institut für Psychologie der Otto-von-Guericke-Universität Magdeburg, Universitätsplatz 2, Geb. 24,
39106 Magdeburg, Germany; martin.krippl@ovgu.de
3 Universitätsklinik für Orthopädie der Otto-von-Guericke-Universität Magdeburg, Leipziger Straße 44,
39120 Magdeburg, Germany; christian.riediger@med.ovgu.de (C.R.);
christoph.lohmann@med.ovgu.de (C.L.); sebastian.illiger@med.ovgu.de (S.I.)
* Correspondence: matthias.vogel@med.ovgu.de; Tel.: +49-391-6714200
† These authors contributed equally.
Received: 9 March 2019; Accepted: 10 May 2019; Published: 16 May 2019
Abstract: Total Knee Arthroplasty (TKA) is the ultima-ratio therapy for knee-osteoarthritis (OA),
which is a paradigmatic condition of chronic pain. A hierarchical organization may explain the
reported covariation of pain-catastrophizing (PC) and dissociation, which is a trauma-related
psychopathology. This study tests the hypotheses of an overlap and hierarchical organization of
the two constructs, PC and dissociation, respectively, using the Western Ontario and McMaster
Universities Osteoarthritis Index (WOMAC), the Childhood Trauma Screener (CTS), a shortened
version of the Dissociative Experiences Scale (FDS-20), the Brief Symptom Inventory (BSI-18),
the Pain-Catastrophizing Scale (PCS), and the Tampa Scale of Kinesiophobia (TSK) in 93 participants
with knee-OA and TKA. Non-parametric correlation, linear regression, and an exploratory factor
analysis comprising the PCS and the FDS-20 in aggregate were run. The three factors: (1) PC
factor, (2) absorptive detachment, and (3) conversion altogether explained 60% of the variance of the
two scales. Dissociative factors were related to childhood trauma, and the PC-factor to knee-pain.
The latter was predicted by absorptive detachment, i.e., disrupted perception interfering with the
integration of trauma-related experiences possibly including invasive surgery. Absorptive detachment
represents negative affectivity and is in control of pain-related anxieties (including PC). The clinical
associations of trauma, psychopathology, and maladaptation after TKA may be reflections of this
latent hierarchical organization of trauma-related dissociation and PC.
Keywords: total knee arthroplasty (TKA); pain-catastrophizing; dissociation; hierarchical structure
1. Introduction
1.1. Hierarchy of Pain-Related Anxieties

The cognitive behavioral construct of pain-catastrophizing (PC) refers to “an exaggerated negative
mental set brought to bear during actual or anticipated painful experience” [1]. It is known to exert a
direct influence on a patient’s response to the experience of pain [2]. Moreover, being a content-specific

J. Clin. Med. 2019, 8, 697
(i.e., pain-related) construct, PC overlaps with other constructs of negative affectivity (e.g., generic
constructs of anxiety, aggression, and alienation) [3]. Therefore, Vancleef et al. [3] have reinforced
the notion of a hierarchical structure of pain-related negative emotional constructs [4], in which
content-specific constructs directly related to pain reside in close vicinity to the actual experience of
pain. On the contrary, generic constructs of (negative) affectivity function as higher-order factors in
the control of content-specific anxiety. For example, a common factorization of PC and higher order
negative affect, as well as coping strategies, revealed a functional hierarchy involving PC and illness
focused coping [5]. Likewise, Kleiman et al. [6] corroborated the hierarchical model by means of a
factor analytic study examining the factor structure of measures of negative affect and content-related
anxieties, including PC in aggregate. Those authors extracted one common factor termed sensitivity to
pain traumatization, which represents a pain-related stress reaction of a posttraumatic character (e.g.,
intrusive thoughts, avoidance, and arousal). Dissociative phenomena are entangled with negative
affect as well, partly as a result of their emotionally destabilizing potential [7], partly by virtue of
their negative affective nature, which led Watson and Clark [8] and Lilienfeld et al. [4] to subsume
alienation (i.e., derealisation/depersonalization) under negative affect. Likewise, Tellegen [9] and
Patrick and Kramer [10] conceptualized alienation (or estrangement) and absorption as components
of negative affectivity. Therefore, not surprisingly, high negative affectivity is linked to dissociative
phenomena in the frame of posttraumatic stress disorder (PTSD) [11]. Not least, Kleiman et al. [6]
postulate symptoms of emotional numbing (i.e., pain-related emotional detachment) to be reflective
of such posttraumatic symptomatology, which occurs in response to pain. Similar to the factor
analytic studies in personality disorder research, those studies indicate the possibility of explaining
the covariation among the observed pain-related variables through the use of latent constructs,
brought to light by factor analysis [12], also with regards to research on chronic pain and its nested
psychological correlates. The knowledge of such systematic interactions between PC, which is an
important predictor of postoperative pain [13], and posttraumatic symptomatology likely offers hints
on adequate psychotherapeutic strategies, as well. For example, dissociative symptoms, if proven to
contribute to chronic pain, would call for a trauma-specific therapy also in this context.
1.2. Dissociation and Pain-Catastrophizing

The DSM-5 defines dissociative symptomatology as the disruption of and /or discontinuity in
the normal integration of consciousness, memory, identity, emotion, perception, body representation,
motor control, and behavior [14]. Dissociation has been hypothesized as a survival mechanism for
surviving a trauma (e.g., sexual) [15]. Holmes et al. [16] have suggested distinct classes of dissociative
symptoms, namely detachment–dissociation and compartmentalization–dissociation, at which the
former is characterized by a sense of separation from the body, self, and environment, whereas the latter
reflects the temporary loss of deliberate control over distinct systems, e.g., memory [17]. Regarding
chronic pain, dissociation is believed to serve to minimize memories of traumatic events, including the
minimization or magnification of the pain perception (the pain focus) [18]. Dissociative symptoms
are frequent in trauma-related psychiatric disorders [19], and, in addition, also occur in pain-prone
medical conditions, such as Osteoarthritis (OA) and rheumatoid arthritis [20]. Likewise, PC is linked
to chronic pain and to worse outcomes of OA-related arthroplasty [21]. Notably, preoperative PC
increases pain perception by means of magnifying pain focus [22], and preoperative pain, in turn,
is a strong predictor of the postoperative algofunction (AF) [23], i.e., the combined status regarding
knee-pain and knee function.
1.3. Psychosomatic Aspects of Osteoarthritis and Total Knee Arthroplasty

OA is a degenerative joint disease causing pain and stiffness, is among the leading causes of chronic
pain and disability [24], and serves well as an example of the progressive, complex, and multifaceted
nature of chronic pain [25]. TKA represents the ultimate therapeutic option for OA of the knee. However,
about a quarter of the patients undergoing TKA experience neither pain-relief nor functional restoration
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J. Clin. Med. 2019, 8, 697
after TKA without there being any detectable medical cause [26]. Moreover, OA is known to coincide
with depression, anxiety, and PC, with exactly these psychological circumstances signifying greater
pain even after TKA [27]. Those reports correspond well to the prediction of postoperative outcomes
by personality characteristics, such as neuroticism or borderline personality [13,28]. Moreover, chronic
pain is connected to specific anxieties related to pain, which include kinesiophobia in addition to PC.
The fear avoidance model of chronic pain posits a circular interaction between the pain focus (that is
PC), the perception of pain as well as the fear of movement and re-injury. As a result, the individual is
prompted to withdraw from activity and social surroundings to the effect of reduced participation, a
less healthy lifestyle, and worsened pain [28].
1.4. Linking Pain-Catastrophizing and Dissociation

Experimental research [29] suggests an overlap between PC and dissociation, and theoretical
considerations [30] do so regarding catastrophic cognitions and dissociative experiences.
This assumption is based on the notion that symptoms, be it dissociation or chronic pain, are perceived
and processed in accordance to the meaning which the individual ascribes to them. Specifically,
according to Ehlers and Steil [30], the co-occurrence of helplessness and detachment dissociation serves
to maintain mental control by preventing exposure to feared material. This theorizing is consistent
with the results of Gómez-Pérez et al. [29], who demonstrated the simultaneous elicitation of PC
and dissociative experiences through a cold pressor task, thus suggesting each of the idiosyncratic
meanings of those symptoms to be mutually influenced. Given the relationship of PC and dissociation
with chronic pain, both likely contribute to the adaptation to chronic pain, possibly based on an
underlying hierarchical structure [3]. Interestingly, researchers have found PC and chronic pain to be
linked to childhood abuse [31], paralleling the respective associations between dissociation and prior
trauma [32].
Considering the relationship between PC and childhood trauma, on the one hand, and between
dissociation and chronic pain on the other, let alone with the hierarchical model in mind, the question
arises as to how those symptoms are connected. Lynn et al. [33] and Giesbrecht et al. [34] have
proposed the action of cognitive processes in dissociation, which may find its reflection in a clinical
population treated for chronic pain in the form of an interaction and functional hierarchy between
the two constructs [3]. The present study tests the hypothesis of an overlap between dissociation
and PC in patients with end-stage knee-OA and chronic pain scheduled for TKA, who are known
to be put under an enormous stress by the imminence of knee-surgery, hypothesizing an overlap
which, in addition, is structured by distinguishable categories of dissociation interacting with the
respective categories of pain-catastrophizing as predicted by the hierarchical model of pain-related
negative affective constructs [4]. We therefore investigate the hierarchically structured organization
possibly underlying PC and dissociation in people with chronic pain scheduled for TKA by means
of an exploratory factor analysis. This is based on the assumption that dissociation would function
equivalently to higher-order constructs of negative affect. Moreover, we assume pain-related anxieties,
including PC and kinesiophobia, to be hierarchically nested, thus possibly lending an explanation to
the covariation of the two constructs by the identification of a latent construct [12]. The rationale behind
this procedure is to improve our theoretical understanding of psychological dispositions, including
childhood trauma and its (adult) correlate, dissociation, for the chronicity of TKA-related pain.

All procedures performed in this study were in accordance with the ethical standards of the
institutional and/or national research committee and with the 1964 Helsinki declaration and its later
amendments or comparable ethical standards. Informed consent was obtained from all individual
participants included in the study.
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J. Clin. Med. 2019, 8, 697
2.1. Sample
A previous study [35] reported a moderate correlation (r = 0.32) between the Dissociative
Experiences Scale [36] and the Cognitive Failure Questionnaire [37]. Given that the PC is also reflecting
a cognitive construct, we used this finding as the basis of our power calculation, which we conducted
by means of G*power (Version 3.1.9.2) [38], arriving at the minimum sample size of n = 74 (two-tailed,
power = 80).
However, 98 patients (53% female) with an average age of 64.64 (±10.55) years (males: 64.27 ± 9.87,
females: 64.98 ± 11.22) scheduled for elective primary TKA for OA were consecutively included in
the present study. The study was approved by the local Institutional Review Board. Inclusion was
based on the aspect of primary TKA for OA and age > 18, while exclusion pertained to the presence
of records of major psychiatric illness. The assessment took place only one to two days before the
operation for the sake of which participants were admitted to the orthopedic department. We enrolled
the participants of the present study consecutively between 2015 and 2017.
2.2. Questionnaire Measures

Knee pain and function were assessed using the Western Ontario and McMaster Universities
Osteoarthritis Index (WOMAC) pain and function subscales (WOMAC A and WOMAC C). Cronbachs
α’s of the WOMAC range from 0.8 to 0.96 and its psychometric properties are judged as being good [39].
The WOMAC used in this study was the Likert version in the format of a numerical rating scale ranging
from 0 to 10.
The brief symptom inventory (BSI-18), a short version of the Symptom Check List 90, assesses
symptoms of depression, anxiety, and somatization in three subscales. Internal consistency for the
subscales ranges between 0.79 and 0.91, discriminant and convergent validity are deemed good, and the
scale is useful as a screening for psychological distress in physically ill populations [40]. This distress
is particularly marked prior to TKA and is also a predictor of a worse postoperative algofunction.
The Fragebogen zu dissoziativen Symptomen (FDS) [41] represents the German version of the
Dissociative Experiences Scale, of which we used the short form (FDS-20). The FDS-20 is composed of
the most sensitive items of the longer version on the condition they reach a Cronbachs α of at least
0.9. The total scale has a good internal consistency (α = 0.93). Items are rated in terms of frequency
on a scale ranging from never present (0%) to always present (100%). However, for the purpose of
the exploratory factor analysis, we transformed the data into four categories reflecting the following
ranges of values: 0%–25%, 26%–50%, 51%–75%, and 76%–100% (of the time), respectively. Rodewald
et al. [42] determined the cut-off of the FDS-20 to be 13, allowing for differentiation between severe
and non-severe dissociation. Means of the FDS-20 are reported to range from 5.0 in non-psychiatric
samples to 25.43 in personality disorders [41]. The factorial structure of the Dissociative Experiences
Scale does not apply to its short version, FDS-20.
The Pain-Catastrophizing Scale (PCS) is a 13-item rating-scale comprising the subscales rumination
(PCS-Rumi), magnification (PCS-Magni), and helplessness (PCS-Help) [43]. It assesses thoughts and
feelings about the pain experience on a 5 point Likert scale. The PCS has proven adequate to excellent
internal consistency (Cronbachs α’s: total score: 0.87, PCS-Rumi: 0.87, PCS-Magni: 0.66, PCS-Help:
0.78). The cut-off serving the distinction between severe and non-severe pain-catastrophizing was set
at 30.
The Tampa Scale of Kinesiophobia (TSK) is a 13 item rating scale rated on a 4 point Likert scale.
Assessing fear of movement and re-injury, it is a valid and reliable instrument with the Cronbach’s α
being 0.73 for its German version [44]. The TSK is divided into two subscales termed activity avoidance
(AA) and somatic focus (SF). Kinesiophobia is essential to fear avoidance, which makes it a relevant
construct also for pain-related psycho-traumatology.
The CTS is a five-item-self-report instrument assessing childhood emotional, physical, and sexual
abuse, as well as childhood emotional and physical neglect. The CTS is derived from the Childhood
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J. Clin. Med. 2019, 8, 697
Trauma Questionnaire for use as a screening for childhood trauma. Cronbach’s α of the CTS is 0.75,
and it is judged to be reliable and valid for its purpose [45].

We used t-testing to compare groups (e.g., male/female) and non-parametric correlations (Kendall’s
Tau) to explore the relationships between continuous variables. The latter choice corresponds to the
skewed distribution of dissociative symptoms in non-psychiatric populations [41]. Principal axis
factor analysis (PAF) [46] was applied for the 33 items of the FDS-20 and the PCS. We were advised
to do so, because the factorial structure of the Dissociative Experiences Scale does not apply to its
short version and, in addition, this chosen procedure suits our intention to identify the presumed
latent structure of the two scales and their observed covariation [4]. The factors were based on the
Kaiser-Guttman-Criterion (eigenvalue > 1) [47] and rotated using the promax method. After that,
parallel analysis [48] was applied, which revealed three factors to extract. We discarded those items,
which had their highest loading in the rotated loading matrices on a factor other than 1, 2, or 3.
The factor scores represent the criteria used in the linear regression analyses. We selected the
corresponding independent variables according to their significance in the preceding non-parametric
correlations. All regressions were controlled for age, gender, and the severity of dissociation or PC
(according to the respective cut-off scores), respectively, each depending on their use as a predictor.
3. Results
3.1. Description of the Sample

The sample was comprised of 98 participants (53% female) with an average age of 64.64 (±10.55)
years (males: 64.27 ± 9.87, females: 64.98 ± 11.22). Five patients refused to participate due to reluctance
to fill in questionnaires. In case of missing data, the participants were contacted and the values
recovered on the occasion of follow-up visits in the orthopedic university clinic. Table 1 displays the
sociodemographic description of the sample with complete data (n = 93). The mean score (SD) and
ranges of the WOMAC A and C scales were as follows: A = 5.3 (2.05) and 0.2 to 10.0, C = 4.88 (2.3) and
0.29 to 12.53.
Table 1. Sociodemographic description of the sample.
Variable N %
Marital Status
single 5 5.4
married/in a relationship 61 65.6
divorced 10 10.8
widow 15 16.1
other 2 2.2
School
no school degree 2 2.15
special school 2 2.15
8 classes 25 26.88
10 classes 43 46.24
12 classes 17 17.20
other 4 4.30
Education
no profess-ion/untrained 24 25.81
completed apprenticeship 46 49.46
university 16 17.2
other 7 7.53
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J. Clin. Med. 2019, 8, 697
Table 1. Cont.
Variable N %
Accommodation
own home 87 93.54
other 6 6.45
Occupation
full-time 28 30.11
part time 8 8.60
at home (housewife) 4 4.30
jobless 1 1.08
pension 51 54.84
other 1 1.08
Mean (SD) of the FDS and the PCS total scores were 4.66 (7.94) and 17.75 (12.35), respectively.
Hence, the FDS-20 scores were skewed with most participants reporting only low levels of
dissociation as expected in a non-psychiatric sample [41]. In total, 22 participants (23.66%) endorsed
dissociation (FDS-total score) at 0% of the time. The mean (SD) of the TSK and the BSI were 21.09 (6.24)
and 6.59 (7.14). The mean (SD) scores of the CTS-subscales were: EN: 1.70 (0.93); PA: 1.47 (0.9); EA:
1.32 (0.8); SA: 1.1 (0.39); and PN: 2.23 (1.27). There were significant (Pearson) correlations between
the TSK and PCS (r = 0.35, p < 0.01), the GSI and pain-related anxieties (TSK: r = 0.21, p < 0.01; PCS:
r = 0.43, p < 0.01), and between the FDS and the TSK (r = 0.22, p < 0.01). Table 2 shows the specific
correlational matrix between the PCS and the FDS-20, respectively.
Table 2. Correlational matrix (Kendall’s tau, p) between the Fragebogen zu dissoziativen Symptomern-20
(FDS-20) total score and the Pain Catastrophizing Scale (PCS) total and subscale scores.
PCS-Rumination PCS-Magnification PCS Helplessness PCS-Total

0.44 0.36 0.47 0.45
FDS-20 total score
<0.01 <0.01 <0.01 <0.01
3.2. Common Factorization of the PCS and FDS-20:

Kaiser-Meyer-Olkin-statistics (KMO) for testing the usability of data for exploratory factor analysis
revealed a very good result (0.901). Parallel analysis after PAF-analysis and promax-rotation revealed
three factors.
Table 3 shows the latent factors at which the exploratory factor analysis arrived, the respective
proportion of explained variance, and the wording and the mapping on the original scale. Items with
the highest loadings on a factor represent that factor (bold face in Table 3). The loss of 13 (factors 4 to 7)
of the 33 items, with which the PAF was fed, is due to the determination of three factors by parallel
analysis. An item was allocated to a certain factor, on the condition that its highest loading was on that
factor. The lowest loading on a factor was 0.38 (Table 3). The most influential factor reflects a compound
of the subscales of the PCS, apparently reflecting the core affective and cognitive responses to pain
typically displayed by patients with chronic pain. It is therefore referred to as the pain-catastrophizing
factor (PC-factor). The second factor, termed absorptive detachment in reference to Allen, Console,
and Lewis (49), contains items that map onto the subscales of amnesia and derealisation of the FDS.
The third factor reflects the conversion subscale of the FDS and was named accordingly. Mean (SD)
of the factor scores for low/high dissociators (in accordance to the respective cut-off point) were
the following: Helplessness: −0.12 (0.9)/1.59 (0.71); absorptive detachment: −0.23 (0.32)/2.87 (2.15);
conversion: −0.2 (0.62)/1.98 (1.81).
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J. Clin. Med. 2019, 8, 697
Table 3. Latent factors (F1-F7) of the PCS and the FDS-20, respectively, along with the respective factor
loadings and wordings of the items. * The number of factors determined to be kept by parallel analysis
was 3. Items with the highest loadings on a factor represent that factor (bold face).
Factors Kept * Factors Lost *
(% Explained Variance) (% Explained Variance)
Scale (Item nr.) F1 (44.7) F2 (13.25) F3 (5.41) F4 (3.6) F5 (3.45) F6 (3.23) F7 (3.1) Wording
PCS (2) 0.94 −0.13 Feeling one can’t go on
Worrying all the time about whether the
PCS (1) 0.92 −0.18 −0.12
pain will end
PCS (4) 0.92 0.25 −0.16 −0.10 Feeling overwhelmed
PCS (6) 0.86 −0.20 0.14 Being afraid of pain getting worse
PCS (3) 0.85 0.15 −0.10 Thinking it’s never getting better
PCS (5) 0.84 Feeling one can’t stand it anymore
PCS (8) 0.70 −0.17 −0.11 0.30 Anxiously wanting pain to go away
PCS (11) 0.64 −0.18 0.15 0.32 Badly wanting pain to go away
I wonder whether something serious
PCS (13) 0.51 0.12 −0.15 0.22 0.35
might happen.
PCS (7) 0.44 0.25 0.17 0.19 Thinking of other painful events
Being in a familiar place but finding
FDS (19) 0.89 0.14
it unfamiliar
Feeling as though one were
FDS (20) 0.86 −0.18 0.19
different people
FDS (8) 0.78 0.30 0.12 −0.15 Hearing voices inside one’s head
Other people and objects do not
FDS (13) −0.11 0.59 0.18 0.29 0.11
seem real
Abidance without movement,
FDS (15) 0.16 0.52 0.21 −0.11 0.31
communication or reaction
Seeing oneself as if looking at
FDS (4) 0.38 0.10 0.32 −0.23 0.33
another person
Feeling one’s extremities are weak, not
FDS (10) 0.87 0.10
being able to use them
Paresthesia or not feeling parts of
FDS (9) 0.68 0.14
one’s body
Feeling uncertain when walking
FDS (18) 0.33 0.55 0.16 0.12
or standing
FDS (12) 0.39 0.46 −0.33 0.14 0.25 Unable to coordinate movements
FDS (2) −0.16 0.74 0.26 Looking at the world through a fog
Not recognizing one’s reflection in
FDS (3) 0.13 0.70 0.12
a mirror
FDS (1) 0.15 0.15 0.51 0.20 −0.26 Feeling one’s body is not one’s own
Remembering past so vividly one seems
FDS (16) 0.15 0.33 −0.11 0.43 0.13 −0.16
to be reliving it
FDS (17) 0.68 0.22 Staring into space
So involved in phantasy that it
FDS (7) 0.23 0.13 0.64
seems real
Being accused of lying when telling
FDS (11) 0.22 0.50 0.31 −0.11
the truth
Finding evidence of having done things
FDS (6) −0.11 0.20 0.68
one can’t remember doing
Not sure if remembered event happened
FDS (5) −0.16 0.11 0.29 0.26 0.57
or was a dream
Not sure whether one has done
FDS (14) 0.38 0.55
something or only thought about it
PCS (9) 0.49 0.60 Unable to stop thinking about pain
Permanently thinking of how one
PCS (10) 0.48 0.58
wished pains to end
PCS (12) 0.29 −0.14 0.23 −0.15 0.54 Nothing one can do to relieve the pain
3.3. Factor Correlations and Interrelation

Table 4 shows the correlational matrix of these factors as well as their correlations with the clinical
variables of interest. The PC-factor and the absorptive detachment factor were highly correlated with
each other (cf. Table 4), but not with the factor conversion. The event of an item loading highly on two
factors did not occur among factors 1 to 3, although the three items of factor 6 had their second highest
loadings on factor 1. Regarding the BSI-18, the conversion factor was only linked to somatization,
whereas the other two were linked to depression and anxiety, as well. The conversion factor—unlike
its companions—lacked an association with TSK-subscales. Knee-pain and function were related to
the PC-factor only, whereas childhood trauma solely showed correlations with dissociative factors.
Based on the cut-off score of the FDS-20, six participants qualified as severe dissociators.
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Table 4. Correlations (Kendall’s Tau, first rows and p values, second rows) of the factors 1 to 3 with
WOMAC and psychometric scores and interfactor-correlations. WOMAC A: knee-pain; WOMAC C:
knee-function; TSK: Tampa scale of kinesiophobia; CEA: childhood emotional abuse; CPA: childhood
physical abuse; CSA: childhood sexual abuse; CEN: childhood emotional neglect; CPN: childhood
physical neglect; GSI: global severity index, -: no correlation could be computed.
Absorptive
PC-Factor Conversion-Factor
Detachment-Factor
0.36 0.09
PC-factor -
0.000 0.27
0.36 0.02
Absorptive detachment-factor -
0.000 0.76
0.09 0.02
Conversion-factor -
0.27 0.76
0.06 0.21 0.13
CEN
0.50 0.02 0.15
0.15 0.20 0.20
CPA
0.09 0.03 0.03
0.18 0.30 0.10
CEA
0.05 0.001 0.29
0.13 0.07 0.06
CSA
0.16 0.44 0.55
0.10 0.22 0.15
CPN
0.2 0.009 0.08
0.28 0.12 0.02
WOMAC A
0.001 0.1 0.8
0.2 0.09 −0.03
WOMAC C
0.01 0.3 0.7
0.36 0.31 0.09
TSK total score
0.000 0.000 0.23
0.33 0.28 0.07
-Somatic focus
0.000 0.001 0.38
0.32 0.31 0.13
-Activity avoidance
0.000 0.000 0.10
0.46 0.41 0.15
BSI-GSI
0.000 0.000 0.06
0.4 0.34 0.27
-Somatisation
0.000 0.000 0.002
0.46 0.35 0.10
-Depression
0.000 0.000 0.22
0.41 0.41 0.11
-Anxiety
0.000 0.000 0.19
Table 5 displays the results of the stepwise linear regression analyses, with the dependent variables
being the factors 1, 2 and 3, and the predictors having been chosen based on the finding of a significant
non-parametric correlation with the dependent variable in the previous step. The PC-factor was best
predicted by the absorptive detachment-factor, but also by depression. The former was best predicted
by activity avoidance, and the conversion factor by high PC. Hence, the two scales were separated by
the factor analysis, but regression revealed their specific interactions in patients with imminent TKA.
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Table 5. Linear regression analyses, dependent variables: factors PC-factor, absorptive detachment,
and conversion. WOMAC A/C: knee-pain/-function; CEA: childhood emotional abuse; CPA: childhood
physical abuse, CEN: childhood emotional neglect, CPN: childhood physical neglect, TSK-SF: subscale
somatic focus (Tampa scale of kinesiophobia), TSK-AA: subscale activity avoidance (Tampa scale of
kinesiophobia), BSI: brief symptom inventory, GSI: general severity index (summary score of the BSI).
Dependent CI CI
Predictor B SE β t p
Variable Lower Upper
Gender 0.18 0.20 0.09 0.94 0.35 −0.21 0.58
Age −0.26 0.01 −0.26 −2.57 0.01 −0.05 0.01
CEA 0.03 0.16 0.02 0.18 0.86 −0.30 0.36
PC-factor Absorptive detachment 0.35 0.15 0.38 2.37 0.02 0.05 0.65
(total model: df = 12; WomacA 0.05 0.08 0.10 0.61 0.55 −0.12 0.22
F = 7.03; WomacC 0.02 0.08 0.04 0.27 0.79 −0.14 0.18
p = 0.000 TSK-SF 0.02 0.05 0.05 0.40 0.69 −0.07 0.11
R2 = 0.61) TSK-AA 0.01 0.04 0.05 0.38 0.71 −0.06 0.09
BSI-Somatisation 0.12 0.09 0.26 1.41 0.17 −0.05 0.29
BSI-Depression 0.14 0.06 0.322 2.13 0.04 0.008 0.26
BSI-anxiety −0.01 −0.07 −0.01 −0.08 0.94 −0.14 0.13
High dissociation −0.93 0.64 −0.26 −1.45 0.15 −2.22 0.36
Gender 0.28 0.24 0.13 1.14 0.26 −0.21 0.76
Age 0.01 0.01 0.05 0.47 0.64 −0.02 0.03
High
0.57 0.50 0.22 1.13 0.26 −0.43 1.56
pain-catastrophizing
Factor absorptive
CPA −0.05 0.18 −0.04 −0.27 0.79 −0.40 0.31
detachment
CEA 0.32 0.21 0.23 1.51 0.14 −0.10 0.74
(df = 13;
CEN −0.26 0.20 −0.21 −1.31 0.19 −0.65 0.14
F = 3.25;
p = 0.001 CPN 0.21 0.11 0.24 1.93 0.06 −0.01 0.43
R2 = 0.41) PC-factor 0.06 0.23 0.06 0.28 0.78 −0.39 0.52
TSK-SF −0.06 0.06 −0.17 −1.16 0.25 −0.17 0.05
TSK-AA 0.09 0.04 0.33 2.15 0.04 0.01 0.18
BSI-Somatisation 0.10 0.10 −0.20 −0.96 0.34 −0.10 0.30
BSI-depression −0.09 0.08 −0.21 −1.19 0.24 −0.25 0.06
BSI-anxiety 0.12 0.09 0.24 1.23 0.22 −0.07 0.30
Gender 0.18 0.19 0.09 0.92 0.36 −0.21 0.56
conversion factor
Age 0.008 0.01 0.08 0.82 0.42 −0.01 0.03
(df = 6;
High
F = 7.09; 0.79 0.28 0.33 2.78 0.007 0.22 1.35
pain-catastrophizing
p = 0.000
CPA −0.012 0.11 −0.01 -0.10 0.92 −0.24 0.22
R2 = 0.39)
GSI −0.018 0.04 −0.12 −0.44 0.66 −0.10 0.06
BSI-Somatisation 0.21 0.12 0.46 1.76 0.08 −0.03 0.44
B = unstandardized regression weights of predictors, SE = Standard errors of unstandardized regression weights,
β = standardized regression weights, t = t-value of regression weights, p = p-value of regression weights,
CI-lower = 95% confidence interval lower border of B, CI-upper = 95% confidence interval upper border of B.
4. Discussion
The present study explored the relationships between childhood trauma, PC, and dissociation
in patients with end-stage knee osteoarthritis scheduled for TKA, based on the assumption of (1) a
phenomenological overlap and clinical interaction [29], and (2) a hierarchical organization [3] between
dissociation and PC [33]. Pain-related anxieties and negative affect (as represented by the global
severity index of the BSI-18) proved highly intercorrelated, as did the FDS and pain-related anxieties,
suggesting that negative affect, pain-related anxieties, and dissociation are nested. This prerequisite of
the hierarchical model of pain-related anxieties aside, the factor analysis separated the FDS and the
PCS, yielding one PCS-(catastrophizing) and two FDS-(dissociative) factors. The three factors together
explained about 60% of the variance of the two scales and were subsequently correlated to knee-pain
and function, as well as to psychopathological distress, including kinesiophobia, and to childhood
trauma scores. All factors showed correlations with psychopathological distress and kinesiophobia,
but the latter was more closely related to the PC-factor. Finally, linear regression showed that the
latter (accounting for 44% of the variance of the two scales according to the factor analysis) was best
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predicted by the absorptive detachment factor. Contrarily, the conversion factor was predicted by
high PC, and the absorptive detachment factor by activity avoidance. Thus, the factors apparently
differ with regard to their elicitation as well as to their maintenance in patients with chronic pain
undergoing TKA. Interestingly, the correlational patterns reveal specific associations between PC
and knee-pain and function, and between dissociation and childhood trauma, respectively. On the
contrary, all three factors showed close relationships with psychopathological distress, except for
the conversion factor, which was not linked to kinesiophobia. Importantly, the regression analyses
controlled for severe dissociation and severe PC, respectively, based on cut-offs, and the correlations
were non-parametric, hence the present results do take the skewed distribution of dissociative symptoms
in this non-psychiatric population into account.
4.1. A Topography of Specific Associations

The absorptive detachment factor is made up by a choice of dissociative symptoms, representing
derealisation/depersonalisation (also referred to as detachment–dissociation) [15] on the one hand,
and items, that are best described as relating to mal-integrated memory (amnesia) and the corresponding
disruptions of identity, on the other. The latter result from the failure to properly contextualize and
encode personal and (auto-) biographic memories constitutive of the self [49,50]. These specific
dissociative experiences represent severe dissociation, as they are causing interruptions to the stream
of consciousness, leading to gaps in identity and to ruminating, self-absorbed states (absorption) due
to the preoccupation with, e.g., dissociative hallucinations [51] or other forms of compartmentalized
traumatic memories. Likewise, jamais-vu (i.e., spurious non-familiarity) experiences are epiphenomena
of severe dissociation [52], which could explain their high loading on the absorptive detachment-factor.
Thus, this latent factor could be indicative of a dynamic interaction between states of detachment from
the body, self, and/or environment, on the one hand, and the resulting lapses in memory formation,
on the other. Moreover, the pain-specific construct of pain-related helplessness behaved as predicted
by the hierarchical model and appears to be hierarchically nested within the generic (higher-order)
construct of negative affect, which, as the present results suggest, does include detachment-dissociation.
4.2. Dissociative Coping: Legacy of Childhood Trauma in TKA and Beyond

This interaction is likely linear, dependent on the severity of dissociative symptoms and therefore
possibly driven by the severe dissociators in the present study. Nevertheless, our results suggest
a principal covariation of the two constructs, and are therefore in-line with [3], who incorporated
alienation (i.e., detachment dissociation) in their concept of pain-related negative affect, although
those authors do not lay their focus on dissociation. Comparable, specific interactions between
the subtypes of dissociation, compartmentalization–dissociation, and detachment–dissociation,
and different kinds of psychopathology, as well as their relation to childhood trauma have been
described regarding psychiatric patients [53]. The respective differences pertain to the differential
influence of detachment–dissociation and compartmentalization–dissociation, respectively, on the
process of coping with psychic, and possibly also psychosomatic, as well as physical distress. While the
population under study here is not psychiatric, it is facing TKA instantaneously and therefore under
an enormous psychological strain. The latter includes a magnifying pain focus, which may initiate a
dissociative response [29], possibly following a similar pattern as has been revealed in a psychiatric
population, in principle. Dissociation is viewed as a means of coping with adversities, such as mental
or physical harm, which makes it relevant to coping with, e.g., severe psychopathology or major
surgery [54]. The latter may be viewed as an interpersonal act of violating the bodily integrity, especially
based on the prior experience of interpersonal trauma.
Unlike other authors [30], we did not find an association between childhood trauma and PC. Rather,
the present findings could suggest that those reports reflect the extent to which variances are being
shared between measures of PC and dissociation. Accordingly, the type of trauma seemingly involved
in the dynamics between PC and dissociation for the most part in the present study is childhood abuse,
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which Sansone et al. [30] also found to be linked to PC. Hence, the present findings suggest preoperative
PC not only to be embedded in psychopathological distress, but also to be hierarchically nested within
the more content-general construct of detachment–dissociation. Considering the trauma model of
dissociation, which posits the causation of dissociative experiences by trauma [32], any cue reminiscent
of an experienced trauma could therefore sensitize the individual by creating the expectation of another
aggressive and hurtful encounter happening [30]. Regarding the dissociative factors, their prediction
by activity avoidance and high pain catastrophizing surprises in that detachment was linked to
kinesiophobia (or more precisely, activity avoidance). Kinesiophobia, apart from being correlated
with catastrophizing, is obviously linked to self-absorbing inner experience and phantasies. That state
possibly prevents the individual from being occupied with any activity other than that. Moreover,
the link between the conversion factor and high PC underscores the relevance of phobic mechanisms
for coping with major surgery [55]. Accordingly, joint function after TKA has been related to anxiety
levels [56], a finding which possibly points to a subgroup of patients undergoing TKA, who are also
suffering from trauma and dissociation.
Hence, in-line with the experimental data [29] indicating a dynamic relationship between
dissociation and PC, the present results suggest dissociation severe enough to interfere with the
consolidation of one’s identity to maximize the psychopathological distress in traumatized individuals
with TKA. This process seems to be driven by a lack of inner cohesion (that is, detachment from
certain aspects of one’s body, self, or environment) and by the systematic interactions between PC and
trauma-related psychopathology. Accordingly, helplessness has been found to mediate the effect of
catastrophizing on pain [57]. Inner cohesion is a reasonable prerequisite of effective self-regulation
and competent mastery; consequently, unfavorable coping styles, such as rumination and self-blame,
have been linked to detachment, a finding [58] possibly relevant to somato-psychic pathology, on a
larger scale.
4.3. Synergism Between Pain-Catastrophizing and Dissociation

This notwithstanding, another effective way to induce dissociative symptoms, as well as PC
in patients with TKA, apparently is to develop emotional distress, which—as many studies could
demonstrate [26,28]—is especially pronounced in the face of imminent TKA. While affection with
feelings of anxiety and depression may be a frequent reaction to facing invasive surgery for most
people [59], the present study illustrates that it echoes the hierarchically structured interaction of
detachment–dissociation and PC. As to the correlational conflation of the FDS-20 and the PCS in
this study, it is consistent with a synergism rather than with the assumption of an antagonistic
nature of their relationship [60]. This is also evident from studies reporting that the two forms of
psychopathology converge to the effect of increasing the propensity for nocebo-like reactions [61],
as one could call the events of impaired postoperative algofunction after TKA in the absence of
medical causes. Moreover, from a theoretical point of view, the universal nature of the non-parametric
correlation between the FDS-scale and the PCS, as well as the prediction of pain-related helplessness
by detachment–dissociation correspond to the literature that conceives dissociation as being bound
to cognitive failures. This stance [34], however, does not necessarily involve a functional hierarchy.
Nevertheless, the latter could reconcile the controversy on the nature of dissociation at least in relation
to pain-related cognitions. Moreover, the present results imply an overlap of PC, as assessed by the
PCS, with various kinds of dissociative symptomatology.
4.4. Forced to the Knee: The Special Implications of Knee-Osteoarthritis

In accordance to this, several studies reported an association of PC either with amnesia or with
depersonalization/derealisation, or both [29,62]. However, the cited studies are concerned with different
samples and, most of all, different pain sites. In order to understand the psychological strain on
patients awaiting TKA, the essentiality of the knee for our two-legged mobility ought to be considered:
The respective patients with TKA are known to suffer markedly from functional problems as a result
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of malposition due to fear of pain and re-injury [63], to depend on help with their personal care and
routine needs [64], and to experience a faster decline in gait speed, allowing for less participation
to be reached as the disorder progresses compared to OA of the hip [65]. In conclusion, the present
study, albeit retrospective and cross-sectional in nature, does encourage important clinical conclusions.
A subgroup of patients with TKA may have specific difficulty coping with TKA as a result of childhood
trauma and dissociative symptomatology and should therefore be offered psychosocial support
based on psychological screenings. Moreover, the remarkable extent of psychopathological distress
born by patients with imminent TKA may lead orthopedic surgeons to administer antidepressants
peri-operatively in order to counterbalance the impact of psychopathological distress on the outcomes
of TKA. As to the caveats of this study, the lack of psychiatric diagnostic interviews, which can hardly
be implemented in an orthopedic setting, deserves mentioning. Moreover, the sample was limited
in size and restricted to patients with OA scheduled for primary TKA and may therefore not be
representative of other indications. Also, the five drop-outs in this study limit the interpretability of
the results, especially since we cannot describe them due to a lack of sociodemographic information,
which they did not provide. Furthermore, the common factorization deployed in the present work is a
controversial procedure, although it offers the possibility of explaining the observed covariation of the
variables under study by the identification of unobserved, latent factors [4] and is, in addition, a proven
method in personality psychology [12]. However, since 13 items were excluded from the analysis by
the parallel analysis, their covariation and latent contribution to the presumed hierarchical organization
of pain-related anxieties and trauma-related symptoms remains obscure, although the contribution of
factors 4 to 7 to the total variance of the two scales was comparatively small. The alternative price to
pay would have been a reduced factor variance in connection with a heightened error variance as a
result of a forceful allocation of the 13 omitted items on factors 1 to 3 based on secondary loadings.
The latter procedure would have caused error correlations to occur, which would oppose the classical
test theory [66]. Nevertheless, the present study is the first to suggest absorptive detachment as a latent
factor crucial for the maladaptation to pain and its chronification. Moreover, the results reinforce the
notion that childhood trauma and dissociation are relevant to coping with surgery and also deserve
diagnostic attention in a surgical setting.
Author Contributions: M.V.: Conceptualization, writing, writing, and review editing L.F.: Data collection and
curation, writing M.K.: Methodology, writing C.R.: Data collection and curation J.F.: Supervision C.L.: Writing
S.I.: Supervision.
Funding: This study was funded by the Heigl-Evers-Stiftung (grant number: 472243/990099).
Conflicts of Interest: On behalf of all co-authors, I declare no conflict of interest regarding this submission.
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217
Journal of
Clinical Medicine
Article
Effectiveness of an Attachment-Informed Working
Alliance in Interdisciplinary Pain Therapy
Ann-Christin Pfeifer 1,2, *, Pamela Meredith 3,4 , Paul Schröder-Pfeifer 5 ,
Juan Martin Gomez Penedo 6 , Johannes C. Ehrenthal 2 , Corinna Schroeter 1 , Eva Neubauer 1
and Marcus Schiltenwolf 1
1 Department of Orthopedics, Trauma Surgery and Paraplegiology, Heidelberg University Hospital,
Schlierbacher Landstr. 200a, 69118 Heidelberg, Germany; corinna_schroeter@t-online.de (C.S.);
eva.neubauer@med.uni-heidelberg.de (E.N.); marcus.schiltenwolf@med.uni-heidelberg.de (M.S.)
2 Institute of Medical Psychology, Center for Psychosocial Medicine, University Hospital Heidelberg,
Bergheimer Str. 20, 69115 Heidelberg, Germany; Johannes.Ehrenthal@med.uni-heidelberg.de
3 School of Health and Rehabilitation Sciences, The University of Queensland, St. Lucia, QLD 4072, Australia;
p.meredith@cqu.edu.au
4 School of Health, Medical and Applied Sciences, Central Queensland University, North Rockhampton,
QLD 4701, Australia
5 Institute of Psychosocial Prevention at the Center for Psychosocial Medicine, University Hospital Heidelberg,
Bergheimer Str. 54, 69115 Heidelberg, Germany; paul.schroeder-pfeifer@med.uni-heidelberg.de
6 CONICET and Universidad de Buenos Aires, C1053 CABA, Buenos Aires, Argentina;
jmgomezpenedo@gmail.com
* Correspondence: ann-christin.pfeifer@med.uni-heidelberg.de; Tel.: +49-0-6221-5635492
Received: 7 February 2019; Accepted: 5 March 2019; Published: 14 March 2019
Abstract: Attachment theory provides a useful framework for understanding individual differences in
pain patients, especially with insecure attachment shown to be more prevalent in chronic pain patients
compared to the general population. Nevertheless, there is little evidence of attachment-informed
treatment approaches for this population. The present study compares outcomes from two different
attachment-informed treatment modalities for clinicians, with outcomes from treatment as usual
(TAU). In both intervention groups (IG1 and IG2), clinicians received bi-monthly training sessions on
attachment. Additionally, clinicians in IG1 had access to the attachment diagnostics of their patients.
All treatments lasted for four weeks and included a 6-month follow up. A total of 374 chronic pain
patients were recruited to participate in this study (TAU = 159/IG1 = 163/IG2 = 52). Analyses were
carried out using multilevel modeling with pain intensity as the outcome variable. Additionally,
working alliance was tested as a mediator of treatment efficacy. The study was registered under the
trial number DRKS00008715 on the German Clinical Trials Register (DRKS). Findings show that while
IG2 was efficient in enhancing treatment outcomes, IG1 did not outperform TAU. In IG2, working
alliance was a mediator of outcome. Results of the present study indicate that attachment-informed
treatment of chronic pain can enhance existing interdisciplinary pain therapies; however, caveats
are discussed.
Keywords: chronic pain; attachment theory; attachment-informed intervention
1. Introduction
Chronic pain syndromes are a result of complex interactions between biological, psychological,
and social influences, including patients’ beliefs about their self-efficacy, hypervigilant monitoring
of bodily sensations, and familial conflict or social support [1–3]. Due to maladaptive behavior or
cognitive responses to acute episodes of pain stemming from these interactions, the pain may become
chronic, affecting the long-term course [4].

J. Clin. Med. 2019, 8, 364
Attachment theory provides a useful framework to classify patients’ relatively stable cognitive,
emotional, and behavioral response styles to stressors (such as pain). These attachment-related
response styles, or attachment patterns, have been linked to disease processes in general [5–8] and to
pain-related diagnoses and processes in particular [9,10]. Hence, the individual attachment pattern
can provide some indications regarding how chronically ill patients behave in treatment; for instance,
with regards to health-care utilization, trust, and compliance with the treatment [6,7] as well as
self-management [11] and coping strategies used [8].
Based on their dominant response patterns, adults can be classified into one of four attachment
styles—one secure style, and the three insecure styles: dismissing, preoccupied, and fearful [12,13]
(see Figure 1). Attachment can also be operationalized as dimensions, with low scores on both attachment
anxiety and avoidance representing secure attachment, and high scores in either attachment anxiety or
avoidance (or both) representing insecure attachment [14].
Figure 1. Different attachment styles described by Griffin and Bartholomew [15].
Evidence in the pain literature suggests that these attachment styles relate to patients’ stress
response, beliefs about their ability to cope with the experience of pain, perceptions of the pain
as threatening, and specific interaction patterns with partners and health care personnel [16,17].
In general, patients with insecure attachment patterns report higher levels of pain [18–20], higher
burden of disability [21], lower levels of pain self-efficacy [17], less functional and more dysfunctional
coping strategies such as catastrophizing [22], and greater levels of depression and anxiety [23,24].
These findings are especially relevant given that insecure attachment styles are overrepresented in
patients with chronic pain [20,21,25,26].
Given available evidence, it is likely that insecurely attached patients have different needs in terms
of both their relationship with the clinician and the treatment [27]. Examples of attachment-informed
therapies can be found within family therapy [28,29], psychoanalytic therapy [30], therapy for
personality disorders [31], and within psychotherapy in general [32]. Traditional interdisciplinary pain
therapy includes physical activation, improvement of mobility, the ability to relax, occupational therapy,
psychological pain management, reduction of pain killer intake, and coping-related interventions.
An attachment-informed treatment approach for people in pain may assist clinicians to deepen their
understanding of the individual patient, individualize treatment, and develop therapy as a safe
place, potentially improving outcomes; however, no evidence in the pain field exists to support
this proposition.
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J. Clin. Med. 2019, 8, 364
In the present study, clinicians in a four-week interdisciplinary multimodal pain treatment

program at the Heidelberg Orthopedic Hospital, Heidelberg University Clinic, were trained
in: attachment theory, attachment-related individual differences, related clinical implications,
and suggestions for building a meaningful working alliance. This training was expected to facilitate
the attainment of the program’s aims by enhancing the working alliance, the therapists’ ability to
provide a secure base for patients, and the therapists’ understanding and support of their patients’
individual attachment-based motivations and needs. The aims of this study were to examine whether:
(a) there is a main effect of group (two attachment-informed groups (IG1 and IG2) versus treatment as
usual (TAU)) on treatment outcome; (b) group effect is mediated by working alliance; and (c) working
alliance is moderated by insecure attachment. The main hypotheses are that:
(1) Patients in IG1 and IG2, who both receive an attachment-informed multidisciplinary treatment,
will report a larger mean reduction in pain intensity between pre-treatment, post-treatment,
and follow-up assessments than patients in the TAU group who receive state-of-the-art
multidisciplinary treatment.
(2) As the interventions (IG1 and IG2) are specifically designed to improve the working alliance,
we expect higher ratings for the working alliance in IG1 and IG2 compared to TAU.
(3) The quality of the working alliance will be the core mechanism of change in IG1 and IG2; that is,
it will be the mediating variable between intervention and outcome.
(4) As patients with higher levels of insecure attachment might not profit from the alliance in the
same way as securely attached patients, we expect this mediation effect to be moderated by
insecure attachment.
2.1. Participants
Of the 545 patients attending the Heidelberg Orthopedic Hospital, University Clinic Heidelberg,
between March 2012 and January 2016, 127 patients did not meet the inclusion criteria to be treated in
the clinic (see below) and another 44 patients declined to participate. Therefore, a total of 374 (68.6%)
were recruited to this study. As seen in the flow chart in Figure 2, 159 of these participants were
assigned to the TAU group, 163 to the IG1 group, and 52 to the IG2 group. Table 1 displays descriptive
details for the demographic variables of the patient population.
Figure 2. Trial flow chart describing the recruitment process of all three study arms.
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J. Clin. Med. 2019, 8, 364
Table 1. Descriptive details for demographic variables for the patient population and comparisons
across treatment groups, n = 374.
TAU n = 159 IG1 n = 163 IG2 n = 52

Variable Statistical Test p Value
M/% SD M/% SD M/% SD
Age 66.67 12.04 58.90 13.01 67.31 12.90 F(2,367) = 0.81 0.45
Gender Female 54% - 54% - 52% - χ2 (2) = 2.50 0.29
Married 61% - 58% - 58% - χ2 (2) = 0.32 0.85
Divorced 18% - 15% - 21% - χ2 (2) = 0.99 0.61
Marital status
Single 15% - 21% - 19% - χ2 (2) = 1.84 0.40
Widowed 6% - 6% - 2% - χ2 (2) = 1.49 0.47
Currently working 47% - 45% - 67% - χ2 (2) = 9.88 0.01*
Unemployed 53% - 55% - 33% - χ2 (2) = 9.88 0.01*
Employment
Old-age pension 71% - 70% - 58% - χ2 (2) = 3.46 0.17
Disability pension 15% - 18% - 27% - χ2 (2) = 370 0.16
Lower/middle secondary 81% - 86% - 77% - χ2 (2) = 2.34 0.27
Education
College/university 19% - 14% - 23% - χ2 (2) = 2.34 0.27
Note: TAU = Treatment as usual, IG1 = Intervention group 1, IG2 = Intervention group 2, M = Mean, SD = Standard
deviation, * p ≤ 0.05.

All participants were enrolled as day-clinic patients in the orthopedic clinic of the Heidelberg
University Hospital, and participated in a four-week outpatient multidisciplinary pain treatment
program, including physiotherapy, occupational therapy, music and dance therapy, and individual and
group psychotherapy. To attend this clinic they must: (1) have experienced chronic pain for at least six
months, for which pain intensity, location, and spreading was not fully explained by specific somatic
pathology; (2) be between 18 and 80 years of age; (3) have previously received standard treatment
consisting of at least one rehabilitation program or two inpatient treatments, which did not yield
lasting effects; and (4) have a diagnosis of somatoform disorder according to DSM-IV. In order to
check whether or not these inclusion criteria were fulfilled, comprehensive diagnostic imaging and
examination by an orthopedic specialist was conducted, as well as an interview with the structured
clinical interview for DSM-IV (SCID) by a trained psychologist.
Exclusion criteria were:
• High C-Reactive Protein (CRP) levels as an indicator of rheumatoid arthritis;

• Acute inflammation of the spine;
• A tumor;
• A diagnosis of psychosis;
• A diagnosis of a bipolar or neurological disorder;
• Insufficient ability to communicate in German.
Use of medication was discouraged throughout the treatment, and the number of patients taking
opioids or equivalent drugs in the outpatient clinic was very low (only 8.6%). While information
regarding medication usage (including antidepressants and antiepileptics) was gathered at all
time-points, it was not part of the exclusion criteria.
2.3. Design
All study procedures were approved by the Institutional Ethics Review Board of the Medical
Faculty, University of Heidelberg. All procedures were in accord with the newest version of the
Declaration of Helsinki [33], as well as with the guidelines for good clinical practice.
After a briefing about the study procedures and aims, all participating patients provided written
consent. The study was conducted in a block design with three patient groups (TAU, IG1, and IG2)
and three assessments times (before treatment = T1, post-treatment = T2, and 6-months follow-up=T3;
see Figure 3). Patients who were registered between March 2012 and September 2013 were assigned
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J. Clin. Med. 2019, 8, 364
to the TAU group, patients who were registered between March 2014 and June 2015 were assigned
to IG1, and patients who were registered between June 2015 and January 2016 were assigned to IG2.
All measures were given in paper pencil format and completed in the clinic for T1 and T2. For T3,
the questionnaires were mailed to the participating patients. A randomized controlled trial was
not suitable for this study because of ethical concerns that patients would be put on a waiting list
for several months. A block design increases the chance that the key influence on outcomes is the
intervention used, and was approved by the Institutional Review Board.
After data collection for the TAU group was complete for all time points, the health care personnel
of the outpatient pain clinic received two initial 90-min training sessions on attachment theory and
its use in the therapeutic context. The intervention training offered to the healthcare professionals
working at the outpatient pain clinic included both (a) general directions for building a meaningful
working alliance; and (b) guidelines for the clinicians to enable them to tailor treatment to the specific
needs of individual patient attachment styles and behaviors. More attachment-related training sessions,
alternating with supervision meetings, were held on a monthly basis to assist clinicians in the practical
application of this approach during interventions for the second (IG1) and third (IG2) study samples.
Further, “situations” (e.g., instances in which the patient misses entire therapeutic sessions or appears
too late to them on a regular basis), which are perceived to be critical for forming a working alliance,
were discussed at the weekly meetings. These situations were subsequently used to structure case
discussions in the bi-monthly 90-min training sessions.
The only difference between the IG1 and IG2 interventions was that, in IG1 only, weekly
team meetings incorporated case reviews with discussion regarding the attachment diagnostics
(i.e., individual attachment styles) of each patient. The IG2 group also had weekly team meetings,
but the clinicians were not informed about the specific attachment style of each patient. Instead, it was
expected that after receiving the attachment-based training sessions, the team would be more sensitive
to the individual attachment behavior of patients without knowing the specific attachment style.
Figure 3. Study design.
2.4. Interdisciplinary Multimodal Pain Treatment

The interdisciplinary multimodal pain therapy provided to the patients in the TAU group
consisted of an intensive, structured interdisciplinary program provided in an outpatient setting
with five hours of treatment per day, five days per week, for four weeks. The treatment included
physiotherapy, occupational therapy, psychotherapy, and medical treatments in both individual and
group modalities. Additionally, patients could participate in Nordic walking and dance and music
therapy, as well as relaxation training and guided physical activity supervised by physiotherapists.
2.5. Attachment-Informed Training

In the attachment-informed approach, the same clinicians received training about attachment
theory and attachment-informed treatment principles [34]. The primary aim was to improve the
working alliance by improving the therapists’ ability to: (a) provide a secure base for patients;
and (b) understand and deal with patients’ individual attachment-focused motivations and needs.
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J. Clin. Med. 2019, 8, 364
They then sought to integrate these attachment approaches and techniques within the treatment
as usual approach. The usual aims of the multimodal pain treatment were retained. Importantly,
the approach did not aim to modify underlying insecure attachment patterns, which would have been
unrealistic within four weeks in this setting.
The motive-orientated working alliance (former known as complementary therapeutic relationship) [35]
informed the development of general guidelines for an improved working alliance. This approach
emphasizes the underlying motives (such as attachment motives) of patients. Using existing literature on
the application of attachment ideas to specific therapeutic settings (e.g., borderline personality disorder,
depression, medically unexplained symptoms, and family and couple therapy [30,36–38]) as a starting point,
specific guidelines were created for developing a working alliance for each attachment style. As an example,
patients with anxious attachment styles might benefit more from an initially concordant approach that
emphasizes the therapist’s role as a secure base. These patients might feel overwhelmed by a program
which is too quick to emphasize autonomy, possibly reinforcing existing fears of rejection and abandonment.
On the other hand, avoidantly attached patients might feel uncomfortable with high levels of proximity or
intimacy, and the amount of guidance and care favored by anxiously attached patients [39,40].
In the interdisciplinary setting, it was necessary that the attachment-based approach be readily
employed by healthcare professionals with diverse professional backgrounds (e.g., doctors, physiotherapists,
occupational therapists, and music and dance therapists); therefore, all guidelines needed to be easily
incorporated into all professional approaches.
2.6.1. Pain Visual Analogue Scale (VAS)

Current pain was assessed by a VAS, asking the patients to rate their acute pain during the present
day on a scale ranging from 0 to 100. Similarly, average pain over the previous week was assessed
using a visual analogue scale ranging from 0 to 100. For rating purposes these scales were collapsed to
indicate values between 0 and 10. Visual analogue scales have been proven to provide a valid and
reliable way of measuring chronic and acute pain [41,42]. VAS were assessed at each time point.
2.6.2. Oswestry Low Back Pain Disability Questionnaire [43]

The Oswestry Low Back Pain Disability Questionnaire is a self-report measure of the functional
disability of the patients and consists of 10 items assessing pain and disability in specific contexts
of life to measure functional disability due to pain [44]. The items are scored on a 6-point Likert
scale ranging from “no functional disability” (0) to “complete functional disability” (5). The original
measure is considered the gold standard in assessing functional disability due to back pain [45].
The present study used the German version of this questionnaire, which has shown very good
internal consistency (α = 0.94) [43]. The original questionnaire (in English) has also shown good
construct validity and test-retest reliability over a span of two weeks (r = 0.82; [46]). In the present
study, the Oswestry Low Back Pain Disability Questionnaire showed good internal consistency, with
Cronbach’s α values ranging from 0.80 at T1 to 0.88 at T3. The Oswestry Low Back Pain Disability
Questionnaire was assessed at each time point.
2.6.3. Experiences in Close Relationships Scale Revised 12—German Version (ECR-RD12) [47]
The ECR-RD12 is a German short version of the ECR-RD scale, which has previously revealed
very good internal consistency (α = 0.91–0.92; [48]). The ECR-RD12 is a self-report measure of
attachment, with questions referring to participants’ behavior in romantic relationships. The ECR-RD12
consists of 12 items, with 6 items loading on two scales: avoidant attachment and anxious attachment.
Items are scored on a 7-point Likert scale ranging from “disagree strongly” (1) to “agree strongly”
(7) [47]. The original English instrument has a stable factor structure, as well as good test-retest
reliability (r = 0.80–0.83) and construct validity [49]. The attachment patterns measured by the
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J. Clin. Med. 2019, 8, 364
ECR-RD12 were treated as continuous variables with mean values computed. Additionally, attachment
insecurity was derived from the ECR-RD12 as a sum score of both scales, with high values representing
attachment insecurity and low scores representing attachment security. In the present study,
the ECR-RD12 showed good internal consistency, with Cronbach’s α values of 0.78 for anxious
attachment and 0.82 for avoidant attachment. The ECR-RD12 was assessed at T1 only.
2.6.4. Inpatient and Day-Clinic Experience Scale—German Version (German TSEB/English IDES) [50]
The TSEB is a self-report questionnaire with 35 items, which assesses various facets of the working
alliance specifically designed for day-clinic patients [50]. Seven scales are calculated: bond with
individual therapist, bond with therapeutic team, agreement on tasks and goals, cohesion with the
patient group, self-disclosure, critical attitude, and positive self-view. Items are scored on a 6-point
Likert scale ranging from “not at all true” (1) to “completely true” (6). The authors have reported
mixed internal consistency, ranging from α = 0.53 for critical attitude to α = 0.89 for positive self-view,
while they found evidence of construct validity with good confirmatory factor analysis model fit. In the
present study, the TSEB showed varying internal consistency ranging from poor to high (from α = 0.58
for critical attitude to α = 0.89 for bond with individual therapist), congruent with the results of the
validation study. The bond with therapeutic team subscale was primarily used, as this was deemed
best fitting for the day-clinic setting. The TSEB was assessed at T2.
2.7. Statistical Analyses

SPSS 22 [51] was used for descriptive analysis and data management, while R [52] was used for
missing data analysis and handling of outliers. Power was computed analytically via the R package
“powerlmm”. Assuming a small to medium effect of the treatment of Cohens d = 0.5, a power analysis
was computed for an ICC of 0.2 for three time-points. According to the power analysis, 95% power
was achieved at a group size of n = 160. Unfortunately, due to the nature of the block design and
complications in recruitment, IG2 had only n = 52 willing participants. Thus, IG2 was underpowered
at only 51% power.
The data contained 9.82% missing values. The group of complete cases did not differ from the
group with missing values on one or more variables in mean or standard deviation on any variable
of interest. All analyses were conducted assuming the data was missing at random (MAR). Under
MAR, observation missingness is assumed to be unrelated to the dependent variable at dropout [53].
Multiple imputations by chained equations (MICE) [54] with 20 iterations were used to impute missing
values for available time points. MICE produces asymptotically unbiased estimations of the data under
MAR assumptions [55]. Using p > 0.001 for the χ2 value of the Mahalanobis distance as a measure of
multivariate outliers, no outliers were identified.
HLM7 software was used for multilevel modeling [56]. We used longitudinal multilevel models
with measurements over time (level 1) nested in patients (level 2), since it can be expected that
measurements within patients over time are non-independent [57]. Multilevel models offer a good
way of handling unbalanced designs, accounting naturally for the different number of measurements
per person [58,59]. To answer the questions regarding whether or not there were significant differences
in level of the outcome variable (pain intensity) at six months follow-up and weekly rate of change
during treatment and follow-up period, dependent on treatment group (IG1 vs. IG2 vs. TAU) we tested
several models. For each outcome variable, we tested a two-level conditional model with time in weeks
(centered at the end of the 6-month follow-up) as the only level-1 predictor. At level two, we included
the treatment conditions as well as attachment anxiety as predictors both of the intercept and the slope
of the model. As patients were nested with therapists, but only four therapists participated in the
study, instead of conducting three-levels to control for therapist effects, we decided to include the
therapist as a covariate (dummy coded) in all models.
Since there was prior evidence from another study conducted at the Orthopedic Hospital that
patient trajectories would be markedly different during treatment as opposed to during follow up,
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we decided to use a piecewise modeling approach. In the earlier study, symptoms declined steeply
during treatment, and started increasing again during follow up. Change in each piece of the model
was estimated using the technique outlined by Smith and colleagues [60] by providing the estimated
error variance at level 1 for the outcomes in the model [60,61]. The level-1 error variance of each
outcome measure was estimated as the product of its measurement error (1-Cronbach’s α) and the
variance of the measure at each time-point.
Full maximum likelihood was used as the estimator in all models. Significance values and
standard errors for fixed effects were computed using Kenward-Roger approximation [62]. Plotting
the fitted against the residual values did not indicate non-constant error variance for any of the models
and visual inspections of Q-Q plots did not reveal marked non-normality for any of the models.
To test mediation and moderated mediation effects, we used PROCESS macro version 2.11 for
SPSS version 22.0 [63]. For these models, the Empirical Bayes estimates of patient’s scores at the end
of follow-up and of the weekly rated of change, estimated in the above-mentioned two-level models,
were used as the outcome variables [57]. Hayes’s models 1 and 14 were used to test mediation and
moderated mediation effects.
3. Results
In terms of descriptive statistics, there were no significant differences between the three groups in
terms of the core study variables (see Table 2).
Table 2. Descriptive details of the core study variables and differences between the three treatment
groups, n = 374.
TAU IG1 IG2

Variable Statistical Test p Value
M/% SD M/% SD M/% SD
Age 53.56 12.04 54.45 13.01 51.92 12.90 F(2,367) = 0.81 0.45
Female 66.7% - 58.9% - 67.31 - χ2 (2) = 2.50 0.29
Average Pain 6.44 1.80 6.74 1.79 6.29 1.75 F(2,371) = 1.80 0.17
Current Pain 5.97 2.08 6.04 2.26 5.38 2.22 F(2,364) = 1.83 0.16
ECR-RD12 Anxiety 2.30 1.39 2.40 1.39 2.37 1.38 F(2,338) = 0.21 0.81
ECR-RD12 Avoidance 2.46 1.22 2.54 1.17 2.43 1.19 F(2,340) = 0.22 0.81
Note: ECR-RD12 Anxiety= Anxious attachment subscale of the Experiences in Close Relationships Scale
Revised 12—German Version, ECR-RD12 Avoidance= Avoidant attachment subscale of the Experiences in Close
Relationships Scale Revised 12—German Version.
Table 3 summarizes correlations among core study variables at intake using Pearson’s correlation
for continuous variables and Spearman-rank coefficients for non-continuous variables. Alpha levels
were adjusted using Bonferroni correction.
Table 3. Correlations among core study variables, n = 374.
Physical ECR-RD12 ECR-RD12

I Gender Average Pain Current Pain
Functioning Anxiety Avoidance
Age 0.12 * 0.15 ** 0.12 * 0.25 *** −0.06 0.19 ***
Gender 0.05 0.06 0.09 0.01 0.08
Average Pain 0.70 *** 0.42 *** 0.01 0.02
Current Pain 0.44 *** 0 0.05
Physical Functioning 0.05 0.1
ECR-RD12 Anxiety 0.22 ***
Note: * p ≤ 0.05; ** p ≤ 0.01; *** p ≤ 0.001.
3.1. Treatment’s Main Effects Analysis

Concerning Hypothesis 1, the conditional model including average pain as the outcome variable
showed no difference between either IG1 or IG2 to TAU at post-treatment (see Figure 4) but a significant
difference at 6-month follow-up in average pain for IG1 compared to IG2 (γ01 = −0.92, SE = 0.45, t(358)
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= −2.027, p < 0.05), in favor of IG2 (see Table 4). Additionally, IG2 worked markedly better in the long
run for patients with high attachment anxiety (see Figure 4). While having significantly worse pain
intensity scores in IG2 after treatment compared to TAU and IG1 (γ03 = −0.52, SE = 0.22, t(358) = 2.32,
p < 0.05), patients with high attachment anxiety achieved the lowest scores of pain at follow-up
(γ23 = −0.02, SE = 0.01, t(358) = −1.78, p = 0.08), although this effect did not reach significance.
Figure 4 shows the effect of insecure attachment across the three treatment groups over time. Gray
shaded areas indicate 95% confidence intervals around the parameter estimates, with darker areas
indicating overlapping confidence intervals.
Figure 4. Effect of attachment on average pain across treatment groups.
Table 4. Results of multilevel model with average pain intensity as outcome, n = 374.
Approx.
Fixed Effect Coefficient Standard Error t-Ratio p
df
For Intercept, β0
Intercept 4.823 0.116 41.556 358 <0.001
IG1 vs. IG2 −0.923 0.269 −2.11 358 0.058
ECR-RD12 Anxiety −0.132 0.092 −1.429 358 0.154
IG2 x ECR-RD12 Anxiety 0.522 0.224 2.322 358 0.021
For Piece 1 slope, β1
Intercept −0.364 0.026 −13.529 358 <0.001
IG1 vs. IG2 0.028 0.073 0.396 358 0.693
ECR-RD12 Anxiety 0.013 0.020 0.660 358 0.510
IG2 x ECR-RD12 Anxiety −0.052 0.064 −0.812 358 0.417
For Piece 2 slope, β2
Intercept 0.018 0.005 3.332 358 <0.001
IG1 vs. IG2 −0.024 0.016 −1.498 358 0.135
ECR-RD12 Anxiety 0.001 0.004 0.023 358 0.981
IG2 x ECR-RD12 Anxiety −0.021 0.011 −1.774 358 0.077
Note: Approx. df = Approximate degrees of freedom, * p ≤ 0.05; ** p ≤ 0.01; *** p ≤ 0.001.
3.2. Mediational Effects Analysis

Although there was no significant difference between TAU and the two intervention conditions,
mediational analyses were conducted to see if there was an indirect effect of treatment condition
on outcome by working alliance, as specified in Hypotheses 2 and 3. For these models we used
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a dummy variable as the independent variable comparing IG2 with TAU (i.e., IG2 = 1, TAU = 0).
IG2 was compared to TAU, since previous analysis hinted that these groups provided the greatest
potential to explore this mediation effect by way of being conceptually different and also boasting
bigger outcome differences than IG1 vs. TAU. The working alliance with team score provided by
the TSEB was introduced as the mediator. For outcome variables we used the estimated score at
post-treatment and at follow-up, as well as the slope (weekly rate of change) of pain intensity, leading
to a total of six mediation analyses.
Regardless of the model, the treatment condition was significantly related to scores at TSEB
(B = 0.23, SE = 0.12, t(179) = 2.003, p < 0.01). Patients in IG2 revealed a TSEB score of an estimated 0.23
units higher than patients in the control group. Furthermore, TSEB scores were significantly related
with average pain at follow-up (B = −0.21, SE = 0.10, t(178) = −2.183, p = 0.03) and the weekly rate of
change in average pain (B = −0.002, SE = 0.001, t(178) = −2.227, p = 0.03). Overall, the indirect effect of
treatment condition by TSEB scores was significant for average pain at the end of follow-up, but not
for the weekly rate of change in average pain.
In the mediational models for current pain, we again found that TSEB scores were significantly
related with current pain at the end of follow-up (B = −0.27, SE = 0.14, t(178) = −1.986, p < 0.05) and
the weekly rate of change in current pain (B = −0.002, SE = 0.001, t(178) = −2.075, p = 0.04). There
was a significant indirect effect of treatment by TSEB scores on current pain at the end of follow-up;
however, the indirect effect of treatment by TSEB scores on weekly change in current pain was not
significant. On the other hand, there was no significant direct effect of treatment on current pain at
follow-up (B = −0.13, SE = 0.21, t(178) = −0.616, p = 0.54) or in current pain weekly change (B = −0.001,
SE = 0.001, t(178) = −0.596, p = 0.55).
3.3. Moderated Mediational Effects Analysis

We conducted moderated mediational effects analysis to check if the mediational effects reported
(indirect effect of treatment by TSEB scores) were, in turn, moderated by patient attachment pattern
(Hypothesis 4). As presented in Figure 5, attachment anxiety significantly moderated the mediational effect
of treatment by TSEB scores on average pain at the end of follow-up (B = 0.23, SE = 0.09, t(155) = 2.628,
p < 0.01) and the weekly change in average pain (B= 0.003, SE = 0.001, t(155) = 2.650, p < 0.01).
Figure 5. Summary of results for moderated mediation analysis. Note: p < 0.05 = *, p < 0.01 = **, c =
direct effect before mediation, c‘ = direct effect after mediation.
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In summary, the mediation analysis indicated a difference in pain reduction between IG2 and
TAU that is mediated by working alliance, measured by the TSEB. This effect, in turn, is dependent
on attachment insecurity, as shown in Figure 6. High values of attachment insecurity negate the
positive effect of the working alliance, while low values reinforce it. This moderating effect extends
to both the average level of pain at follow-up (−1 SD ECR-RD12 Insecurity B = −0.11, SE = 0.7; +1
SD ECR-RD12 Insecurity B = 0.01, SE = 0.03), and rate of change during therapy (−1 SD ECR-RD12
Insecurity B = −0.0012, SE = 0.0008; +1 SD ECR Insecurity B = 0.0001, SE = 0.0003).
Figure 6. Moderated effect of attachment insecurity on the relationship between working alliance and
average pain after follow up.
4. Discussion
The primary aim of this study was to examine whether providing attachment-informed training to
clinicians in an interdisciplinary pain program could influence pain outcomes compared to treatment
as usual (TAU). According to Hypothesis 1, it was anticipated that this would be the case. Results
only partially supported this hypothesis, however. Patients in IG2 reported a larger mean reduction in
average pain intensity between pre-treatment and post-treatment assessments compared to patients in
both IG1 and TAU groups. Perhaps surprisingly, IG2, in which therapists were not informed of patient
attachment style, outperformed IG1, where therapists knew the attachment styles. Thus, this additional
knowledge seemed to have had an adverse effect. There are a number of possible explanations for
this phenomenon. Most likely, with therapists at the IG1 stage being new to attachment theory,
they will have been consolidating information and gaining new perspectives throughout the IG1
stage, which would presumably support practice during IG2. The clinicians in IG1 may have felt
overwhelmed, having access to a large amount of new information and to the patients’ attachment
style, and trying to integrate these components “on the job”. The changed role of the therapist,
in which they serve as a form of substitute attachment figure for the patients that has to attune to
each individual attachment pattern by addressing the specifically related needs [64], also takes time to
develop. These considerations are particularly relevant given the short length of the treatment (four
weeks). It may also be that knowing a patient’s attachment style might evoke a form of unconscious
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stigma on the part of the therapist, which may impact on the therapeutic relationship. Another possible
explanation is that attachment, as measured by the ECR-RD12, is not representative of the attachment
behavior exhibited during therapy, therefore misleading clinicians in IG1. Finally, the smaller number
of participants in IG2, and reduced power, may have impacted on results. Further research is needed
to gain clarity about these possible explanations.
The interdisciplinary pain therapy includes physical activation, improvement of mobility,
the ability to relax, occupational therapy, psychological pain management, reduction of pain killer
intake, and coping-related interventions. An ordinary treatment can last up to 4 weeks for a full-time
intensive outpatient treatment. Due to the limited time available, it is generally very difficult to
build a stable and trusting work-alliance between the therapist and the patient to allow the patient
to properly take in the content of the therapy. Even though it is much harder for insecure patients
to establish and maintain a stable and trusting working alliance [21,65], the development of trust is
essential for the success of therapy [40,66]. One therapeutic approach that already includes these
relationship related aspects is the psychodynamic interactional group therapy by Nickel and Egle [67]
that already works with these relationship aspects in a clinical setting, with a focus on the working
alliance and conflict management during 40 sessions.
The second hypothesis was that the intervention groups (IG1 and IG2) would produce stronger
average working alliances compared to TAU. This was partly supported, with patients in IG2 reporting
significantly better working alliances compared to those in TAU. Working alliances for patients in IG1
did not differ from those in TAU.
The third hypothesis suggested that the quality of the working alliance would be the core
mechanism of change in IG1 and IG2 (i.e., the mediating variable between intervention and outcome).
As expected, working alliance was found to be a strong mediator between the intervention effect and
treatment outcome, suggesting that training staff in attachment theory and its implications for people
in pain can help to improve the working alliance, and therefore strengthen outcomes. This is consistent
with expectations based on parent-infant attachment-based interventions, where training in attachment
theory enhanced maternal-sensitivity and infant-security [68]. Literature and some empirical evidence
point to the importance of the working alliance for the course of the treatment and its outcomes,
as well as for the maintenance of positive treatment outcomes after therapy ends [69,70]. The results
of this study correspond to attachment theoretical assumptions [7,71] as well as to the impact of the
working alliance [72]. This is one of first studies to consider these assumptions in a clinical setting with
a longitudinal design, and the first to do so with chronic pain samples.
As expected in Hypothesis 4, the link between working alliance and pain outcome was moderated
by insecure attachment. Patients with higher levels of insecure attachment reported poorer working
alliances compared to securely attached patients, with implications for pain outcome. This finding
was evident despite attachment-informed intervention provided in this study, suggesting that this
intervention did not counter the effects of attachment insecurity on pain outcome. While anticipated,
based on previous research, this finding suggests the need for attachment-informed modifications to
treatment that extends beyond the therapeutic alliance. The mentalization-based approach [73] has
been successfully utilized with mostly insecure attached patient groups before (e.g., [74,75]) and could
provide a useful addition in working with chronic pain patients. In contrast to the focus of present
study on how to establish a good therapeutic alliance with insecure patients, the mentalization-based
approach could aid in understanding how the communication in these therapeutic alliances works
and how the patient mentalizes the relationship. This might help explain why the insecure patients
were not able to profit from the therapeutic alliance in the same way as did secure patients.
Findings support working alliance as a mechanism of change linked to patient attachment.
Nevertheless, the path model also indicated that the insecure patients in IG2 were the only insecure
patients who did not experience deteriorations in pain during the post-treatment phase. Although
the mean difference in pain at the 30-week follow-up was non-significant, this trend hints at the
attachment-specific training having a positive effect on post-treatment adjustment to pain [76,77].
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The results from TAU, on the other hand, replicate the evidence from the empirical literature stating
that insecurely attached patients have, on average, poorer treatment compliance [7,71] and adjustment
to pain [4,9,78].
Limitations
The primary limitation for this study can be found in the study design. The block design was
chosen even though the optimal design for the study would have been a randomized controlled trial
(RCT), with patients being randomly assigned to one of the treatment arms with separate groups of
treating clinicians. However, this was not feasible in this orthopedic hospital setting. The very limited
number of clinicians working at the outpatient department would have made it impossible to divide
the clinicians into more than one interdisciplinary pain treatment at a time. A future study replicating
the results of the current study might use a multicenter trial in order to control for spillover effects,
while providing an adequate number of clinicians for an RCT design.
Another limitation is the failure to control for therapist adherence to the treatment guidelines.
While the clinicians were regularly asked during the weekly team meeting whether or not they
implemented the training contents into their treatment routine, no adherence data is available. Future
studies might profit from development of an intervention manual with clearly defined treatment
characteristics and working mechanisms to support development of systematic adherence ratings.
These might then be ascertained either from expert rated videos of therapy sessions, or a comparable
approach, such as a manualized adherence rating. This information could be used as a control variable
or descriptively to support interpretation of findings.
While the main objective of the present study was to compare the three treatments, i.e., investigating
between-person effects, we were also interested in the trajectories of treatment over time in our treatment
groups. The short duration of the treatment combined with relatively long assessments at each measurement
point has resulted in having only the minimum number of time points needed for longitudinal modeling.
This, combined with large standard errors for our estimates of within-person effects, render low levels
of certainty in those estimates. For future studies of multimodal pain therapies with attachment focus,
a shorter assessment battery with more time points is needed to properly investigate the trajectories in
patients’ symptoms over time.
A further methodological issue is the sample size of IG2 and the high dropout rate at follow-up
across all treatment arms. While the non-significant t-tests across dropouts and non-dropouts suggest
that dropout is not systematically related to outcome, the question remains why the dropout at T3 was
so high. Although significant effects between treatments were found, the results of the present study
need to be replicated in a future study with all treatment arms being powered equally.
Finally, the intervention was provided over only a four-week period. If adapted for longer
outpatient settings, more pronounced differences may be seen over time as, hypothetically, attachment
patterns might slowly alter over the course of therapy, increasing the positive effect of the working
alliance on pain over time.
5. Conclusions
The results of the present study provide preliminary support for the utility of incorporating
attachment-informed interventions with existing multimodal pain therapies in short-term outpatient
settings. Although the clinicians trained in the attachment-informed treatment only had four weeks to
implement the treatment, this approach was more effective in reducing perceived pain intensity in IG2
relative to TAU. Findings suggest that one reason for this was the facilitation of a more stable working
alliance between the therapist and the patient in the attachment-informed treatment. Findings also
suggest that classifying patients into one of the four attachment categories prior to treatment may not
be needed to build a stable working alliance. As a result of this study, a number of needs are identified.
First, there is a need for a written manual with a detailed description of the intervention to support
clinicians to adhere to and integrate the new techniques of the intervention into their daily treatment
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routine. Second, based on this manual, measures of treatment adherence by clinicians should be
developed. Finally, more in-depth attachment-informed treatments should be developed, manualized,
and evaluated. It is anticipated that these steps will contribute to even greater and more lasting clinical
improvements, especially for those with insecure attachment patterns.
Author Contributions: Study concept and design, A.-C.P., C.S., and J.C.E.; collection of data, A.-C.P. and C.S.;
analysis and interpretation of data, A.-C.P., P.S.-P., and J.M.G.P.; statistical analysis, A.-C.P., P.S.-P., and J.M.G.P.;
writing, original draft, A.-C.P.; writing, review and editing, A.-C.P., P.M., P.S.-P., and J.C.E.; visualization, A.-C.P.
and P.S.-P.; supervision, P.M., J.C.E., E.N., and M.S.; access to data, all authors.
Funding: This research was funded by the private foundation “Psychosomatik der Wirbelsäulenerkrankungen”
(“Psychosomatics of spine disorders”), as well as the Federal Ministry of Education and Research, grant
number 01DR17021.
Acknowledgments: The authors gratefully acknowledge the support of the staff and clients of the Department of
Orthopedics, Trauma Surgery, and Paraplegiology at Heidelberg University Hospital. We would like to thank
the private foundation “Psychosomatik der Wirbelsäulenerkrankungen” (“Psychosomatics of spine disorders”),
as well as the Federal Ministry of Education and Research for funding this work. The authors would also like to
acknowledge the support of Prof. Jenny Strong at the end of the manuscript.
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235
Journal of
Clinical Medicine
Article
Effects of Adding Interferential Therapy
Electro-Massage to Usual Care after Surgery in
Subacromial Pain Syndrome: A Randomized
Clinical Trial
Manuel Albornoz-Cabello 1 , Jose Antonio Sanchez-Santos 2 , Rocio Melero-Suarez 3 ,
Alberto Marcos Heredia-Rizo 1, * and Luis Espejo-Antunez 4
1 Department of Physiotherapy, Faculty of Nursing, Physiotherapy and Podiatry, University of Seville,
41009 Seville, Spain; malbornoz@us.es
2 High Resolution Hospital, Andalusian Health Service, Utrera, 41710 Sevilla, Spain; jossansan@alum.us.es
3 Department of Podiatry, Faculty of Nursing, Physiotherapy and Podiatry, University of Seville, 41009 Seville,
Spain; rms-1000@hotmail.com
4 Department of Medical-Surgical Therapeutics, Faculty of Medicine, University of Extremadura,
06006 Badajoz, Spain; luisea@unex.es
* Correspondence: amheredia@us.es; Tel.: +34-954486507
Received: 13 January 2019; Accepted: 30 January 2019; Published: 2 February 2019
Abstract: Subacromial pain syndrome (SAPS) is a prevalent condition that results in loss of function.
Surgery is indicated when pain and functional limitations persist after conservative measures,
with scarce evidence about the most-appropriate post-operative approach. Interferential therapy
(IFT), as a supplement to other interventions, has shown to relieve musculoskeletal pain. The study
aim was to investigate the effects of adding IFT electro-massage to usual care after surgery in adults
with SAPS. A randomized, single-blinded, controlled trial was carried out. Fifty-six adults with
SAPS, who underwent acromioplasty in the previous 12 weeks, were equally distributed into an
IFT electro-massage group or a control group. All participants underwent a two-week intervention
(three times per week). The control group received usual care (thermotherapy, therapeutic exercise,
manual therapy, and ultrasound). For participants in the IFT electro-massage group, a 15-min IFT
electro-massage was added to usual care in every session. Shoulder pain intensity was assessed
with a 100-mm visual analogue scale. Secondary measures included upper limb functionality
(Constant-Murley score), and pain-free passive range of movement. A blinded evaluator collected
outcomes at baseline and after the last treatment session. The ANOVA revealed a significant group
effect, for those who received IFT electro-massage, for improvements in pain intensity, upper limb
function, and shoulder flexion, abduction, internal and external rotation (all, p < 0.01). There were
no between-group differences for shoulder extension (p = 0.531) and adduction (p = 0.340). Adding
IFT electro-massage to usual care, including manual therapy and exercises, revealed greater positive
effects on pain, upper limb function, and mobility in adults with SAPS after acromioplasty.
Keywords: electric stimulation therapy; manual therapies; musculoskeletal pain; pain assessment;
range of motion; shoulder pain
1. Introduction
Shoulder complaints are a common musculoskeletal disorder. The one-year prevalence of shoulder
pain in the general population ranges from 5% to 47%, while the lifetime prevalence has been estimated
up to 67% [1]. Work-related physical and psychosocial factors may be associated with onset and/or
worsening of shoulder pain within the working-age population [2]. Among shoulder complaints,

J. Clin. Med. 2019, 8, 175
subacromial pain syndrome (SAPS) is the most common disorder that result in loss of function,
increased pain sensitivity [3], and impaired quality of life, accounting for up to 70% of consultations in
primary care [4]. SAPS is characterized by persistent pain around the acromion, which usually worsens
during or after lifting the upper extremity [5], and embraces clinical diagnosis such as subacromial
impingement and rotator cuff tears [6]. The clinical course of SAPS remains unclear, and previous
evidence suggests that 50% of adults with chronic SAPS may only recover after 10 to 18 months of
initial onset [7]. This leads to a considerable economic burden [8], due to absenteeism from work,
productivity loss, and high expenditure for health care services [9].
A great diversity of conservative interventions, combining pharmacological and physical therapy
treatments, is often used to decrease pain and enhance function in SAPS [5]. There exists; however,
very limited evidence about the effectiveness of existing treatments to improve the functional
limitations associated with this condition [10]. Amongst them, exercise therapy has been suggested
as the core conservative treatment [11]. Likewise, the use of deep dry needling has shown to
relieve shoulder pain [12], and ultrasound-guided injection therapy is widely used before surgery,
with good outcomes in the short-term [13,14]. Surgical intervention is mainly indicated when
pain and functional limitations persist after conservative measures, and for patients with clearly
distinguished clinical signs [11,15]. Indeed, there is conflicting evidence about the efficacy of surgery
compared to conservative approaches [16,17], or no treatment [15]. Despite that, the frequency of
acromioplasty has dramatically increased in the last decades [18,19]. There is; however, scarce evidence
about the most-appropriate post-operative intervention for SAPS, with exercise therapy showing
good results [20,21].
Interferential therapy (IFT) is a highly popular treatment modality in the clinical setting,
which involves crossing two medium frequency currents to generate a low-frequency beating effect in
the deep tissues [22], and can be used alone or combined with massage [23]. Although IFT is purported
to provide pain relief and increased blood flow to the tissues [24], there is still inadequate evidence to
support its use as a sole intervention for pain management in musculoskeletal disorders in general [22],
and in shoulder pain in particular [25,26]. Nevertheless, IFT as a supplement to other interventions has
demonstrated advantages over placebo and control treatments for reducing musculoskeletal pain [27],
although there are conflicting findings on this issue [28]. Current research also highlights the need for
high quality clinical trials assessing the effectiveness of multimodal approaches for SAPS [29].
The study aim was to investigate the effects of adding IFT electro-massage to a two-week usual
care protocol, compared with the usual care protocol alone, on pain intensity, upper limb functionality,
and shoulder passive range of motion in adults with SAPS who underwent acromioplasty. It was
hypothesized that adding IFT electro-massage to the usual care intervention would achieve higher
effectiveness than the sole use of the usual care regime.
2. Methods
2.1. Study Design

A single-blinded (the evaluator assessing the outcome measures remained blinded to the
participants’ allocation group) randomized controlled trial was carried out. The Consolidated
Standards of Reporting Trials (CONSORT) statement and checklist were followed. The research
protocol was conducted in accordance with the Declaration of Helsinki statement of ethical, legal,
and regulatory principals to provide guidance for health-related research involving human subjects.
The study was approved by the Ethical Research Committee of the Hospital Universitario Virgen
del Rocío, Sevilla, Spain (project code CEI 2012PI/172, approval date: September 26th 2012),
and prospectively registered (Clinical Trials.gov, Identifier NCT03338283). All participants provided
written informed consent.
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J. Clin. Med. 2019, 8, 175
2.2. Participants
Adult patients with shoulder pain, who underwent acromioplasty in the 12 weeks before
data collection, were referred by an orthopedic surgeon at a large public hospital in Southern
Spain. Before surgery, SAPS was diagnosed following a positive response to clinical examination
(Hawkins–Kennedy test, drop-arm test, external rotation lag sign, and empty can test) and radiologic
diagnostic criteria to differentiate SAPS from other conditions (e.g., bone or joint abnormalities) [30].
A detailed description of the clinical tests can be found elsewhere [31]. For the diagnostic accuracy
of clinical examination, a negative response to the Hawkins–Kennedy test appears to rule out
SAPS (pooled sensitivity and specificity, 79% and 59%, respectively) [32]. The drop-arm test or
the external rotation lag sign (specificity, 90–97%) are likely to rule in SAPS when positive [30],
and the empty can test is a reliable and helpful tool to confirm subacromial impingement syndrome
(87% specificity) [33]. Overall, the combination of imaging features and clinical tests can help
to confirm the presence of SAPS [30]. Acromioplasty was considered a feasible intervention for
patients between 20 and 80 years, with anterior shoulder pain lasting more than three months [34],
and who received previous conservative treatment (manual therapy, pharmacological treatment,
and use of corticosteroid injections) with no satisfactory results [35]. Those participants with a
self-reported pain intensity ≥30mm in the visual analogue scale (VAS), and a score <45 points on
the personal psychological apprehension scale (PPAS) [36], were invited to participate. The PPAS is
a valid, reliable, and simple-to-handle tool to assess the subjects’ apprehension to receive electrical
stimulation therapy [37]. The exclusion criteria were as follows: Any contraindication to the use
of IFT (Table 1) [38,39]; previous cervical spine or shoulder surgery; a history of neurological or
mental illnesses; diagnosed central or peripheral nervous system diseases [23]; concomitant fracture
in the neck/shoulder; altered sensitivity to tactile stimuli or loss of sensation in the neck/shoulder
or upper extremity [6]; concomitant radiological diagnosis of osteoarthritis of the glenohumeral
or acromioclavicular joints; fibromyalgia or rheumatoid arthritis [23]; having received injections of
corticoids or hyaluronic acid following surgery; symptoms of frozen shoulder [40]; impaired cognition
or communication; and being involved in an on-going medico-legal dispute.
Table 1. List of contraindications to the use of interferential therapy.
Contraindications
• Acute inflammation
• Pregnancy
• Use of electronic devices, including cardiac pacemakers
• Active deep vein thrombosis or thrombophlebitis
• Tumoral diseases
• Use of metal implants when the subject refers unpleasant sensations
• Untreated hemorrhagic conditions or active bleeding tissues
• Recently radiated tissues
• Active tuberculosis, infected tissues, or wounds with underlying osteomyelitis
• To the neck or head in individuals with previous seizures
• To anterior neck, carotid sinus, over the eyes, or reproductive organs
2.3. Study Protocol

An external website (http://www.randomization.com) was used to complete the randomization
schedule for treatment order, considering a 1:1 ratio distribution of participants in the study groups (IFT
electro-massage and control group). An external assistant safeguarded the randomization sequence
and prepared sealed opaque envelopes concealing the treatment order allocation. Following baseline
allocation, demographic and clinical data were initially collected. A blinded evaluator collected all
measurements at baseline and immediately after the last treatment session. The treatment protocol
consisted of a two-week intervention regime. Three treatment sessions, each lasting around 70–85 min,
were made per week and supervised by a physiotherapist with more than 15 years of clinical experience.
239
J. Clin. Med. 2019, 8, 175

Participants were asked to rate their worst shoulder pain intensity during the last 24 h using
a 100-mm VAS, with 0 denoting “no pain” and 100 denoting “extreme and unbearable pain” [41].
Minimal clinically-important differences for the VAS are based on a 15–20% change [42], or a decrease
above 14 mm [43], following intervention.
The upper limb functionality was evaluated using the Constant-Murley score, which consists of a
100-point scale, with final values representing different functional levels: excellent (>80), good (65–79),
medium (50–64), and bad (<50) [44]. The minimal detectable change for the Constant-Murley score has
been set at 17 points for individuals with subacromial impingement syndrome [45].
The Simple Goniometer iPhone®app (version 1.1, Ockendon.net, Oswestry, England) was used
to assess the shoulder pain-free passive range of movement. An iPhone®3GS, iOS 4.3.5 (Apple,
Cupertino, CA, USA) was fixed to the participants’ arm with an armband bracelet (Kalenji, Villeneuve
d’Ascq, France). The recordings of shoulder range of motion were made twice (2-min break between
assessments), using the average value of the two measures for further analysis. Before assessments,
participants were asked to stop the evaluator when they started to feel low-intensity pain during
movement (below 20 mm in the VAS). To evaluate shoulder flexion and extension, participants were
seated with back support and no armrests, and the iPhone®was fixed on the lateral side of the arm
(2 cm proximal to the glenohumeral joint). For shoulder abduction, participants kept the same position,
and the iPhone®was placed on the ventral side of the arm (2 cm proximal to the glenohumeral joint).
Shoulder adduction was assessed with the participant lying supine, with 90 degrees of shoulder
flexion (or the maximum possible pain-free flexion), and with the iPhone®placed on the ventral side
of the arm. Internal and external rotation were evaluated with participants in supine, with 90 degrees
of shoulder abduction (or the maximum possible pain-free abduction), 90 degrees of elbow flexion,
forearm in neutral position, and the iPhone®was placed in the ventral side of the arm (2 cm proximal
to the glenohumeral joint). During all assessments, the evaluator applied gentle pressure to the
arm or forearm until the edge of movement was reached [46], and maximum caution was taken to
minimize the scapular motion by keeping the shoulder and back in contact with the back support.
A smartphone inclinometer or virtual goniometer is an easy-to-use, valid, and reliable tool, comparable
to other clinical methods, to assess shoulder range of motion in healthy subjects and in individuals
with shoulder disorders [46–48]. The Simple Goniometer iPhone®app has shown to be reliable and
possesses concurrent validity [49].
2.5. Interventions
Participants in the control group underwent an usual care protocol involving: Fifteen minutes of
transcutaneous infrared thermotherapy (INFRA-2000, Enraf-Nonius BV, Rotterdam, The Netherlands) [50];
35 min of active, self-assisted, and isometric exercise therapy [51,52]; 20 min of manual therapy to
retrain scapulohumeral movement and to provide soft and pain-free shoulder traction [51]; and 5 min
of pulsatile ultrasound (Sonopuls 490®, Enraf-Nonius BV, Rotterdam, The Netherlands) over the
acromium and scapulohumeral area, with a 5 cm2 head, and using a frequency of 3 Mhz and a power
of 1.2 w/cm2 . For participants in the IFT electro-massage group, a 15-min IFT electro-massage over
the neck-shoulder and the glenohumeral joint was added in every treatment session to the usual
care treatment previously described. A bipolar application, using a carrier frequency of 4000 Hz at
constant voltage and an amplitude-modulated frequency of 100 Hz, was administered. The current
intensity was set at a medium-high level, but always adapted to individual tolerance, to achieve a
“strong but comfortable tingling” without evoking visible muscle twitches [28]. Two rubber electrodes
(6 × 8 cm) were fitted inside sponges of equal size. The sponges were dampened with hot water to
avoid unpleasant sensations and to allow a normal sliding over the skin during the electro-massage [23].
Some needles with hot water were prepared to dampen the sponges during the procedure, if required.
The physiotherapist wore vinyl gloves and moved the sponges over the neck, shoulder and scapular
areas. Occasionally, the therapist performed slight traction of the glenohumeral joint, and stretching
240
J. Clin. Med. 2019, 8, 175
of the neck-shoulder muscles (e.g., upper trapezius and levator scapulae) while administering the
IFT (Figure 1).
Figure 1. Interferential therapy electro-massage alone (a) or combined with stretching (b).

The sample size calculation was based on detecting: (1) a 15% change in self-reported pain
intensity [42]; and (2) a 17-points difference in the Constant-Murley score in the comparison between
groups after intervention [45]. Taking into account a one-tailed hypothesis, an alpha value of 0.05,
a desired power of 90%, and a high effect size (d = 0.8), 28 participants were required per study group
(G*Power, version 3.1.9.2, Heinrich Heine University, Düsseldorf, Germany).
Statistical processing of the data was carried out using the PASW Advanced Statistics (SPSS Inc,
Chicago, IL, USA), version 24.0. Data were reported as mean (standard deviation), and confidence
intervals (95% CI). The Shapiro–Wilk test was used to test the normal distribution of the study variables.
Differences in the outcome measures were detected using a repeated measures analysis of variance
(ANOVA), with the group (IFT electro-massage or control) as the between-subjects factor, and time
(baseline or immediately after intervention) as the within-subjects factor. Post-hoc comparisons
(Bonferroni) were performed for significant effects. Eta-squared (η2 ) was used to calculate the effect
size (small, 0.01 ≤ η2 < 0.06; medium, 0.06 ≤ η2 < 0.14; and large, η2 > 0.14). Statistical significance
was set at a p value < 0.05.
3. Results
Sixty-six individuals who underwent acromioplasty were assessed for eligibility between
December 2017 to April 2018. Finally, fifty-six participants (30 females, 53.6%), aged between 23
to 76 years (mean age ± SD, 49.6 ± 12.4), met the eligibility criteria and were recruited. There were no
adverse reactions or dropouts during the study protocol (Figure 2).
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J. Clin. Med. 2019, 8, 175
Figure 2. CONSORT flowchart diagram of study participants.
Table 2 lists the baseline characteristics of participants in the study groups. At baseline, there were
no between-group differences for any study variable (all, p > 0.05), except for participants’ height
(p = 0.029).
Table 2. Baseline characteristics of participants in the study groups (mean ± standard deviation, or in
frequency percentages).
Intereferential Therapy
Control Group
Variable Electro-Massage Group p Value
(n = 28)
(n = 28)
Mean age (years) 47.2 ± 11.6 51.9 ± 13.1 0.159
Sex (female) % (n) 42.9% (12) 64.3% (18) 0.111
Height (cm) 170.18 ± 9.21 164.64 ± 9.27 0.029
Weight (kg) 80.53 ± 12.72 75.71 ± 15.44 0.208
Body mass index (kg/m2 ) 27.76 ± 3.37 27.93 ± 5.08 0.884
Arthroscopy surgery % (n) 85.7% (24) 89.3% (25) 0.689
Days after surgery * 42 (21–58) 51 (18–62) 0.221
Affected shoulder; right % (n) 50% (14) 57.1% (16) 0.595
PPAS 34.21 ± 4.74 33.54 ± 9.78 0.743
Visual analogue scale (mm) 69.82 ± 16.74 65.71 ± 20.75 0.419
Constant-Murley score
29.68 ± 10.4 29.71 ± 12.24 0.991
(0–100)
Shoulder flexion (◦ ) 103.61 ± 30.89 107.07 ± 32.53 0.684
Shoulder extension (◦ ) 40 ± 10.79 40.18 ± 13.3 0.956
Shoulder abduction (◦ ) 84.43 ± 27.5 84.25 ± 29.56 0.981
Shoulder abduction (◦ ) 34.5 ± 12.08 30.86 ± 9.78 0.221
Shoulder internal rotation (◦ ) 29.32 ± 14.75 32.21 ± 8.86 0.440
Shoulder external rotation (◦ ) 59 ± 17.22 62.96 ± 20.74 0.378
* Median and interquartile range. PPAS—personal psychological apprehension scale.
Table 3 includes the baseline, post-intervention scores, and the mean differences in the within-
group and between-group comparisons for all outcome measures. Both interventions significantly
improved pain perception, upper limb functionality and shoulder passive range of motion in all
directions (all, p < 0.001). For the between-group analysis of the mean score changes after intervention,
the ANOVA revealed a significant group effect, for those included in the IFT electro-massage group,
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J. Clin. Med. 2019, 8, 175
for the decrease in shoulder pain intensity (F = 29.82; p < 0.001; η2 = 0.35), the improvement in the
Constant-Murley score (F = 29.45; p < 0.001; η2 = 0.35), and the increase in pain-free passive shoulder
flexion (F = 21.51; p < 0.001; η2 = 0.28), abduction (F = 7.77; p = 0.007; η2 = 0.12), internal rotation
(F = 31.97; p < 0.001; η2 = 0.37), and external rotation (F = 8.26; p = 0.006; η2 = 0.13). There were no
differences between groups for shoulder extension (F = 0.39; p = 0.531; η2 = 0.007) and adduction
(F = 0.92; p = 0.340; η2 = 0.017).
Table 3. Baseline, post-intervention values, and mean score changes after intervention of the outcome
measures; mean ± standard deviation (95% confidence interval).
After the Within-Group

Between-Group
Baseline Two-Week Changes after
Mean Changes
Intervention Intervention
Visual Analogue Scale (mm)
–37.14 ± 13.22
IFT Electro-Massage Group 69.82 ± 16.74 32.68 ± 13.64 –18.92 ± 3.46
(–42.27 to –32.01) *
–18.21 ± 12.71 (–25.8 to –11.97) †
Control Group 65.71 ± 20.75 47.5 ± 22.95
(–23.14 to –13.28) *
Constant-Murley Score (0–100)
26.39 ± 5.9
IFT Electro-Massage Group 29.68 ± 10.41 56.07 ± 10.96 10.71 ± 1.97
(24.1 to 28.68) *
15.67 ± 8.61 (6.74 to 14.68) †
Control Group 29.71 ± 12.24 45.39 ± 13.82
(12.33 to 19.01) *
Shoulder Flexion (◦ )
43.25 ± 16.75
(36.75 to 49.74) *
23.92 ± 14.32 (10.96 to 27.67) †
Control Group 107.07 ± 32.53 131 ± 25.93
(18.37 to 29.4) *
Shoulder Extension (◦ )
12 ± 7.21
IFT Electro-Massage Group 40 ± 10.79 52 ± 9.86 1.21 ± 0.92
(9.2 to 14.79) *
10.78 ± 7.21 (–2.64 to 5.07)
Control Group 40.18 ± 13.3 50.96 ± 10.38
(7.99 to 13.57) *
Shoulder Abduction (◦ )
37.75 ± 15.86
(31.6 to 43.9) *
25.5 ± 17.01 (3.43 to 21.06) †
Control Group 84.25 ± 29.56 109.75 ± 30.1
(18.9 to 32.09) *
Shoulder Adduction (◦ )
11.03 ± 7.27
IFT Electro-Massage Group 34.5 ± 12.08 45.54 ± 10.87 –2.25 ± 2.33
(8.21 to 13.85) *
13.28 ± 10 (–6.93 to 2.43)
Control Group 30.86 ± 9.78 44.14 ± 12.94
(9.4 to 17.16) *
Shoulder Internal Rotation (◦ )
21.28 ± 7.71
(18.29 to 24.27) *
10.78 ± 6.09 (6.77 to 14.22) †
Control Group 32.21 ± 8.86 43 ± 11.2
(8.42 to 13.14) *
Shoulder External Rotation (◦ )
23.5 ± 13.82
IFT Electro-Massage Group 59 ± 17.22 82.5 ± 10.94 9.46 ± 3.2
(18.14 to 28.86) *
14.03 ± 10.61 (2.86 to 16.06) †
Control Group 62.96 ± 20.74 77 ± 16.63
(9.92 to 18.15) *
* Indicates significant differences in the within-group comparisons (all, p < 0.001). † Indicates significant differences
in the between-group comparisons. IFT—interferential therapy.
4. Discussion
The present findings demonstrated that including IFT electro-massage in a two-week usual
care protocol, combining manual therapy, exercises, thermotherapy, and ultrasound, achieved better
immediate results on shoulder pain intensity, upper limb function, and pain-free passive range of
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J. Clin. Med. 2019, 8, 175
movement (except for shoulder extension and adduction), compared with the sole use of the usual
care regime, in adults with SAPS who underwent recent shoulder surgery.
The decrease in shoulder pain intensity and the improvement in upper limb functionality was
significantly higher, with a high effect size, for participants who received IFT electro-massage, although
individuals in both groups reduced their shoulder pain after the two-week protocol above the minimum
clinically important difference for the VAS [42,43]. On the contrary, changes in the Constant-Murley
score surpassed the 17-point clinically relevant threshold [45] only for those in the IFT electro-massage
group. The passive shoulder range of movement increased by 20–40% in the control group, and by
30–70% in the IFT electro-massage group. The differences between groups for shoulder pain-free
passive mobility achieved a high effect size for shoulder flexion and internal rotation and a medium
effect size for shoulder abduction and external rotation. To date, there has been a single previous
study investigating the effects of IFT electro-massage [23]. This former trial used IFT as a sole
intervention in individuals with chronic low-back pain and concluded greater improvements on pain,
disability, and quality of life, compared to the use of superficial massage. These positive effects were
explained based on the purported capacity of IFT to stimulate cutaneous sensory nerves and evoke
mild vasodilation [23]. To the author’s knowledge, this is the first study assessing the effectiveness of
a multimodal intervention including IFT electro-massage in adults with post-operative shoulder pain
after acromioplasty.
There is a huge debate about the clinical impact of including IFT and other electrotherapeutic
modalities for the management of chronic shoulder pain. Conflicting to the current results, the addition
of IFT to exercise and/or manual therapy did not demonstrate greater clinical effects on shoulder
pain and disability, compared to the use of exercise and/or manual therapy alone, in individuals
with non-specific soft-tissue shoulder disorders [53], or with unilateral shoulder impingement
syndrome [54]. Similarly, Nazligul et al. [28] recently concluded that IFT does not provide additional
effect to a multimodal approach including cryotherapy, exercise, and non-steroidal anti-inflammatory
drugs for patients with SAPS. On the contrary, it has been demonstrated that the combination of
IFT with shoulder exercises [55], ultrasound, thermotherapy, and stretching [56] is effective in the
management of frozen shoulders. Likewise, the use of IFT alone has shown to be clinically effective
to relieve pain during movement and to increase pain-free passive shoulder mobility in hemiplegic
shoulder pain [57] and, when combined with exercise therapy, seems to improve pain, function,
and quality of life in individuals with shoulder impingement syndrome [58]. In the latter study,
the effect of combining IFT with exercise therapy was; however, similar to that of including ultrasound
or transcutaneous electrical nerve stimulation instead, in the intervention protocol [58]. Indeed,
IFT seems to be a potential, although modest, effective supplement to other interventions to decrease
pain, compared to control or placebo treatments, in musculoskeletal pain disorders [27]. There are;
however, many controversies on this issue [25,26], and the heterogeneity and methodological problems
across studies make it difficult to reach conclusive statements.
This inconclusive evidence about the impact of using IFT, alone or in addition to other conservative
approaches, persists when considering other chronic musculoskeletal pain conditions, such as neck or
low-back pain [59]. There are some plausible explanations to account for this issue. First, the carrier
frequency of the IFT current differs among studies, and this may influence the hypoalgesic response
after stimulation [60]. Second, the use of electrotherapy may evoke a long sustained placebo-induced
pain relief effect [61]. In this sense, most of the previous studies investigating the role of IFT on shoulder
pain have not included sham IFT as a control intervention [54–56,58]. Third, the clinical context and
the social connection between patient and therapist seem to modulate the effect of IFT [62,63], although
these aspects have been scarcely controlled in the existing literature. Finally, only one previous trial
has evaluated the effects of IFT, compared to sham IFT, on post-operative pain, and range of motion in
patients undergoing knee surgery [64]. Even though IFT showed positive findings on increasing range
of motion, and reducing pain, medication intake, and swelling [64], more definite conclusions need to
be built upon more high-quality evidence [27].
244
J. Clin. Med. 2019, 8, 175
Some potential study limitations should be mentioned. First, the study did not include a sham
IFT electro-massage group. Second, only immediate results after the last session of the two-week
intervention protocol were collected, thus it would be highly relevant to investigate the medium and
long-term follow-up effects of IFT on post-operative pain in further studies. Third, the therapist in
charge of the interventions was not blinded to participants allocation group. Finally, further research
is warranted to investigate if different results could be expected using different current parameters.
5. Conclusions
Adding IFT electro-massage to a two-week supervised usual care protocol combining manual
therapy, exercises, ultrasound, and infrared thermotherapy achieved better results on decreasing
shoulder pain, and improving upper limb functionality and shoulder pain-free passive range of
motion, compared to usual care alone, in adults with SAPS who underwent recent acromioplasty.
Author Contributions: Conceptualization, M.A.-C. and J.A.S.-S.; Methodology, M.A.-C., J.A.S.-S., R.M.-S.,
A.M.H.-R., and L.E.-A.; Formal analysis, M.A.-C., J.A.S.-S., R.M.-S., and A.M.H.-R.; Investigation, M.A.-C.,
J.A.S.-S., R.M.-S., A.M.H.-R., and L.E.-A.; Resources, M.A.-C., J.A.S.-S., and R.M.-S.; Data curation, M.A.-C.,
J.A.S.-S., R.M.-S., and A.M.H.-R.; Writing—Original draft preparation, M.A.-C., J.A.S.-S., R.M.-S., A.M.H.-R.,
and L.E.-A.; Writing—Review and editing, M.A.-C., J.A.S.-S., R.M.-S., A.M.H.-R., and L.E.-A.; Visualization,
M.A.-C., J.A.S.-S., and A.M.H.-R.; Supervision, M.A.-C., J.A.S.-S., A.M.H.-R., and L.E.-A.; Project administration,
M.A.-C., J.A.S.-S., and L.E.-A.
Acknowledgments: The authors of this manuscript certify that they have no financial or non-financial interest
(including research funding) or involvement with any commercial organization that has a direct financial interest
in any matter included in this manuscript.
Conflicts of Interest: The authors declare no conflicts of interest.
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Article
Eye Gaze Markers Indicate Visual Attention to
Threatening Images in Individuals with Chronic
Back Pain
Zoë C. Franklin 1, *, Paul S. Holmes 1 and Neil E. Fowler 2
1 Musculoskeletal Science and Sports Medicine Research Centre, Manchester Metropolitan University,
Manchester M15 6BH, UK; p.s.holmes@mmu.ac.uk
2 Vice Chancellor’s Office, University of Salford, Salford M5 4WT, UK; n.fowler1@salford.ac.uk
* Correspondence: z.franklin@mmu.ac.uk; Tel.: +44-161-247-5528
Received: 20 November 2018; Accepted: 27 December 2018; Published: 31 December 2018
Abstract: Research into attentional biases and threatening, pain-related information has primarily
been investigated using reaction time as the dependent variable. This study aimed to extend
previous research to provide a more in depth investigation of chronic back pain and individuals’
attention to emotional stimuli by recording eye movement behavior. Individuals with chronic back
pain (n = 18) were recruited from a back rehabilitation program and age and sex matched against
17 non-symptomatic controls. Participants’ eye movements were recorded whilst they completed a
dot probe task, which included back pain specific threatening images and neutral images. There were
no significant differences between chronic pain and control participants in attentional biases recorded
using reaction time from the dot probe task. Chronic pain participants, however, demonstrated a
significantly higher percentage of fixations, larger pupil diameter, a longer average fixation duration
and faster first fixation to threatening compared to neutral images. They also had a significantly
longer average fixation duration and larger pupil diameter to threatening images compared to control
participants. The findings of this study suggest eye gaze metrics may provide a more sensitive
measure of attentional biases in chronic pain populations. These findings may have important
therapeutic implications for the patient and therapist.
Keywords: chronic pain; attentional biases; eye gaze
1. Introduction
Attentional biases are a selective attention towards or away from a stimulus, which is both specific
and salient to an individual’s current environment and situation [1] and can result in a variety of
cognitive, behavioral and physiological responses. Excessive attentional biases towards pain have been
hypothesized to contribute towards the promotion of pain-related anxiety, fear of pain-related activity,
physical disability and exacerbations in the pain experience [2]. Attentional biases towards pain-related
stimuli have been proposed in theories of attention and pain [3,4]. The pain-specific models explain an
individual’s attentional response to the presence of pain-related stimuli. Todd et al. [5] proposed the
threat interpretation model of attentional biases, suggesting that there is a relationship between an
individual’s interpretation of threat, which then influences their attentional bias towards it. As threat
interpretation increases, initial vigilance towards pain-related stimuli increases; the level of the threat
then influences whether the individual is able to disengage from the threat or avoid the threat.
Meta-analyses [6–8] have reported that pain participants have an attentional bias towards threat
related information compared to controls, although with low effect sizes of 0.1–0.3 which may be due,
in part, to the lack of consistency with the type of pain-related stimuli (e.g., words or pictures; sensory
or affective pain). Within the most recent review [8], the majority of studies used word-based stimuli

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or pain-related faces, rather than pictures associated with movement. Kourtzi and Kanwasher [9]
have identified that pictures which have implied physical movement lead to greater activation of
the extended motor system, compared to images without implied movement. Therefore, it could be
suggested that the increased motor activity associated with movement-related images might represent
a marker of a more valid cognitive response to movement-related emotional stimuli.
Attentional biases have been assessed, traditionally, using the dot probe paradigm [10].
This technique captures a momentary cross-section of attention at the stimulus offset.
Therefore, the method does not indicate duration of attention or attentional exertion to stimuli [11].
The use of eye-tracking equipment, however, can address some of these limitations and allows
researchers to record location and duration of gaze fixations. In addition, eye-tracking also provides
the opportunity to measure pupil diameter as an index of attentional effort [12]. Eye gaze markers
can, therefore, provide researchers with a range of additional metrics to improve the understanding of
attentional biases in chronic pain patients.
Several studies have utilised the dot probe method in conjunction with eye tracking and identified
a bias towards pain-related information. Unfortunately, however, these studies were all conducted with
pain-free undergraduate students, using pain-related words [13,14] or faces [15–17]. While these studies
do provide some insight into the mechanisms associated with attention to pain-related information,
further research is needed to be conducted in patients suffering from chronic pain. To our knowledge,
only three studies have used eye movements to examine attentional biases to pictorial stimuli, and these
were with chronic headache populations [18,19] and mixed chronic pain groups [20]. Both Liossi et
al. [18] and Schoth et al. [19] used a visual search task to assess the attentional biases of chronic
headache patients. Participants were shown four facial expressions (pain, angry, happy and neutral).
Both studies [18,19] identified that the pain group demonstrated a significantly higher proportion
of initial fixations on the pain face, compared to the other facial expressions. Furthermore, Liossi
et al. [18] found that patients had an initial shift in their attention towards pain stimuli, but then
maintained their gaze on happy” images. There was no evidence that pain patients maintained their
gaze on pain related images. These findings support the theoretical models of pain and attentional
biases [3–5] and propose that attentional biases may play an important role in the maintenance of
chronic headache. Fashler and Katz [20] investigated the attentional biases of undergraduate students
who were experiencing a variety of chronic pain conditions (e.g., neck/back, migraine, ankle/knee,
stomach, hip, arm, eye and jaw pain). Participants completed a dot probe task using injury related
(e.g., needle being inserted into the skin, black eye, open wound, burned skin) and neutral images
while their eye movements were recorded. Reaction time results revealed that chronic pain individuals
responded faster to neutral stimuli in contrast to the injury related images. In contrast, the eye tracking
data demonstrated that chronic pain individuals maintained attention towards injury related pictures.
Supporting Todd et al.’s [5] theory that as the interpretation of threat increases, vigilance towards the
threat also increases. To date, however, no study has investigated the attentional biases of a chronic
back pain patient population using both the dot probe paradigm and eye tracking approaches.
The aim of this study, therefore, was to provide a more in depth investigation of chronic back pain
patients’ attention to pain-related images in comparison to non-symptomatic controls by recording eye
movement behavior whilst participants also completed a dot probe task. We hypothesized that chronic
back pain participants would have: (i) a significantly higher percentage of fixations to threatening
stimuli compared to controls; (ii) a longer average fixation duration to threatening images; and (iii)
exhibit a faster reaction time to threatening images in the dot probe task.
2. Method
2.1. Participants
Participants were recruited from a back rehabilitation program at a UK NHS trust (n = 18) and
an age and sex matched non-symptomatic control group was recruited from the university and
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local area (n = 17). Chronic pain participants had been suffering from back pain for a minimum of
three months. Non-symptomatic controls were recruited through advertisements through unsolicited
noticeboards and electronic advertising. Ethical approval was granted by NRES Committee North
West Greater Manchester Central and by Manchester Metropolitan University Ethics Committee.
All participants provided written informed consent to take part in this study. Inclusion criteria for the
back pain group were: (i) over 18 years of age; (ii) a referral to a hospital-based back pain management
program for non-specific musculoskeletal pain; (iii) pain duration of >3 months; and (iv) normal or
corrected to normal vision. Inclusion criteria for the control group were: (i) over 18 years of age;
and (ii) normal or corrected to normal vision. Exclusion criteria for the control group were: (i) any
form of current or recent chronic or recurrent pain; and (ii) regular (daily or near daily) use of any
form of analgesic medication.
2.2. Materials
2.2.1. Dot Probe Paradigm

All participants completed a dot probe task comprising 20 practice trials and 150 experimental
trials (100 threat-neutral, 50 neutral-neutral). The threat images were taken from the Photograph Series
of Daily Activities (PHODA) image bank [21] (back pain specific and showing movements known to be
associated as threatening and evoking pain or pain-related fear, for example lifting or bending tasks).
The neutral images were taken from the International Affective Picture System (IAPS) [22] and included
images of neutral activities, faces and inanimate objects. The presentation of images were randomized
for each participant. Dot probe stimuli were presented on a 23-inch screen (HP EliteDisplay E231,
Hewlett-Packard Company, Palo Alto, CA, USA) with a 1920 × 1080-pixel resolution and a 100 Hz
refresh rate. Participants were told to engage actively with the pictures that were presented to them on
the screen. Each trial began with a central fixation cross presented for 500 ms, followed by an image
pair on the left and right side of the screen, either threat-neutral or neutral-neutral pairs presented for
500 ms. Following presentation of the image pair, a probe stimulus (a pair of dots either vertical or
horizontal) was presented in the location of either the emotional or the neutral image and remained
displayed until the patient/participant responded (see Figure 1). Participants were instructed to press,
as quickly and accurately as possible, one of two keys to identify the probe presented. The inter-trial
interval varied randomly between 500 and 1250 ms. Response times shorter than 200 ms or longer
than 1200 ms were removed from the data. Incorrect responses were also excluded from the analysis.
Errors and outliers accounted for 2.5% of the data.
Congruent (e.g., the target followed the emotional picture) and incongruent (e.g., the target
followed the neutral picture) attentional bias scores for threatening images relative to neutral were
calculated for each participant from the response time data using the formula:
Congruent = ((Trpr + Tlpl)/2) − ((Nrpr + Nlpr + Nrpl + Nlpl)/4) (1)
Incongruent = ((Tlpr + Trpl)/2) − ((Nrpr + Nlpr + Nrpl + Nlpl)/4) (2)
T = threat, N = neutral, p = probe, r = right position, l = left position.
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Figure 1. An example of the three stages of the dot probe task in the neutral threat condition.
2.2.2. Eye-Gaze
While participants completed the dot probe paradigm, their eye movements were also recorded.
Eye movement data were recorded with an Applied Science Laboratories Mobile Eye System (ASL;
Bedford, MA, USA) using a dark pupil tracking technique throughout the dot probe paradigm.
This method uses the relationship between the pupil and a reflection from the cornea to calculate the
point of gaze in relation to an external scene camera. The ASL software computes the relationship
between the pupil and cornea to locate gaze within a scene at a sampling rate of 30 Hz. The system
has an accuracy of 0.5◦ of visual angle, a resolution of 0.10◦ of visual angle, and a visual range of 50◦
horizontal and 40◦ vertical.
Previous eye gaze research has assessed: (i) percentage of fixations on the threat or neutral stimuli;
(ii) average pupil diameter when fixating on the threat and neutral stimuli; (iii) average time spent
fixating on the threat or neutral stimuli; and (iv) first fixation time on either the threat or the neutral
stimuli. In this study, visual fixations were defined as maintaining gaze on a specific location on the
screen for at least 100ms and a maximum fixation radius of 1◦ , as employed in previous studies [13,16].
2.3. Procedures
Participants were asked to sit at a desk in a black booth and facing the screen approximately
60 cm in front of them and at eye level. A desk mounted chin rest was used to reduce participants’
head movements ensuring that participants’ eyes were level with the middle of the monitor on which
the stimuli were presented. This ensured that each participant’s eyes were in the same location relative
to the camera and monitor. A 9-point calibration check was used prior to the start of testing. A drift
check was conducted before each trial and recalibration performed when necessary. Participants were
instructed to look at the fixation cross before each trial to standardize the starting location of their eye
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gaze and were told to engage actively with the pictures that were presented to them on the screen.
Participants provided demographic information after testing was completed to allow for age and
sex matching.
2.4. Preparation of Eye Gaze Data

Eye gaze data were analyzed using ASL Results Plus (Applied Science Laboratories, Bedford,
MA, USA). Each trial was parsed into 150 (100 threat-neutral, 50 neutral-neutral) separate trials.
Individual trials were then analyzed by drawing two separate areas of interest (AOIs) around the
threatening and neutral images. From this, the number of fixations, average fixation duration, and pupil
diameter when fixating in each AOI were calculated. A fixation was defined as any gaze that remained
stable (within 1 degree of visual angle) for a duration of over 100 ms. In accordance with previous
studies [23], participants with missing data of more than 15% over the 150 trials were excluded from
the study. Based on this criterion, no participants were excluded from the study. Due to technical
difficulties with the eye tracking equipment, no eye movement data were recorded for one of the
non-symptomatic control participants and this participant was excluded from further analysis.
2.5. Data Analysis

A series of 2 × 2 analysis of variances (ANOVA) were conducted on the eye gaze data (percentage
fixation, average pupil diameter, average fixation duration, first fixation time), with group (patient,
control) as a between participants independent variable, and image type (threat or neutral image) as a
within participants variable. A 2 × 2 ANOVA of the probe response time data with group (patient,
controls) as the between variable, and probe position (probe in same versus different location to
threatening image) as the within participants variable. Bonferroni post hoc analyses were used where
needed to clarify significant main effects and interactions. Alpha was set at p < 0.05 and effect sizes
were calculated using Cohen’s d.
3. Results
3.1. Group Characteristics

The chronic pain and control groups did not differ significantly in sex ratio (chronic pain: 12 (66%)
female, control group 11 (64%) female, χ2 = 0.15, p= 0.90) or age (chronic pain group: M = 46.72, SD ±
9.97 years; control group: M = 40.47, SD ± 9.23 years, t(33) = −1.92, p = 0.07).
3.2. Power Analysis

Post-hoc power analyses [24] were conducted for the dot probe and eye movement data.
The power analysis results for the dot probe data were: power = 0.64 (α = 0.05; β = 0.36) d = 0.6,
for number of fixations to threat; power = 0.82 (α = 0.05; β = 0.18) d = 0.8, and neutral images;
power = 0.83 (α = 0.05; β = 0.17) d = 0.9. The power analysis results for the average pupil diameter;
power = 0.76 (α = 0.05; β = 0.24) d = 0.8; average fixation duration; power = 0.86 (α = 0.05; β = 0.14)
d = 0.9; and for total fixation duration; power = 0.99 (α = 0.05; β = 0.01) d = 1.6. Therefore, despite
the relatively modest sample size there was sufficient power to have confidence in the findings from
the study.
3.3. Eye Gaze Reliability Analysis

Internal consistency, reflecting the interrelatedness of items on a test was calculated using
Cronbach’s alpha for both the control group and the patient group for each outcome variable. For both
patient and control groups there was high reliability for percentage fixation count, pupil diameter
and first fixation time (Cronbach’s α = 0.73–0.93). Average fixation duration subscale, however, had a
relatively low reliability, Cronbach’s α = 0.62–0.64 (see Table 1).
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Table 1. Internal consistency measured with Cronbach’s alpha for each outcome variable in the patient
and control group.
Group Outcome Measure Cronbach’s α

Patient Percentage fixation count 0.750
Pupil diameter 0.802
Average fixation duration 0.644
First fixation time 0.722
Control Percentage fixation count 0.927
Pupil diameter 0.743
Average fixation duration 0.616
First fixation time 0.725
3.4. Percentage Fixation Count

The results of the two way mixed ANOVA showed a significant interaction between participant
group and image type, (F (1, 33) = 32.01, p < 0.001) and a significant main effect of stimuli type, (F
(1, 33) = 11.05, p = 0.002). Pairwise comparisons indicated that chronic pain individuals attended to
threat images (M = 34.07, SD ± 10.58) significantly more than neutral stimuli (M = 18.27, SD ± 9.32);
t(17) = 6.25, p < 0.001, d = 1.57, 95% CI [0.80, 2.29] (see Figure 2). For the control group, there was no
significant difference between the percentage fixation count to threat (M = 21.61, SD = 5.97) or neutral
(M = 25.72, SD ± 8.39) stimuli; t(16) = −1.69, p = 0.11, d= 0.5, 95% CI [−1.24, 0.13].
40
35
30
% fixation count
25
Neutral
20
Threat
15
10
0
Patient Control
Figure 2. The percentage of fixations (±SE) on threatening or neutral stimuli in the patient and control
group. ** indicates p < 0.01.
3.5. Average Pupil Diameter

A significant main effect of group was found (F (1,33) = 23.71, p = 0.0001); t-tests revealed that
individuals in the pain group (M = 5.69, SD ± 0.18 mm) had a significantly larger pupil diameter
compared to controls (M = 4.62, SD ± 0.18 mm), d = 0.5, 95% CI [4.29, 7.32]. A significant main effect for
stimuli type was found (F (1, 33) = 11.65, p = 0.002); t-tests showed that participants had a significantly
larger pupil diameter when attending to threatening (M = 5.30, SD ± 1.33 mm) compared to neutral
(M = 4.64, SD ± 1.23mm) stimuli, t(34) = 2.71, p = 0.01, d= 0.9, 95% CI [−0.16, 1.17] (Figure 3). There was
no significant interaction effect found (F (1,33) = 0.10, p = 0.749).
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7 ΎΎ
ΎΎ
6
Average pupil diameter (mm)
5
4
Neutral
3 Threat
0
Patient Control
Figure 3. The average pupil diameter (mm) (±SE) for the patient and control groups when attending
to threatening and neutral stimuli. ** indicates p < 0.01.
3.6. Average Fixation Duration

A significant group x image type interaction F (1, 33) = 10.90, p = 0.02, and a significant main
effect of group F (1, 33) = 4.72, p = 0.03 was found. T-tests revealed that pain participants demonstrated
a significantly higher average fixation duration on threatening (M = 219.18, SD ± 53.06 ms) compared
to neutral stimuli (M = 185.04, SD ± 38.68 ms); t(34) = −2.16, p = 0.03, d = 0.8, 95% CI [−0.06, −0.001]
(Figure 4). There was no significant difference between the control group’s average fixation duration
towards threatening or neutral stimuli. T-tests revealed that the pain group (M = 219.18, SD ±
53.06 ms) had a significantly longer average fixation duration to threatening stimuli compared to
controls (M = 174.88, SD ± 17.36 ms); t(68)= −3.35, p = 0.03, d = 0.9, 95% CI [−0.04, −0.004].
Ύ
250
Average fixation duration (ms)
200
150
Neutral
Threat
100
50
0
Patient Control
Figure 4. The average fixation (ms) duration (±SE) to threatening and neutral stimuli for the patient
and control group. * indicates p < 0.05.
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3.7. First Fixation Time

There was a significant interaction of group x first fixation time (F (1,33) = 35.21, p = 0.0001), and a
significant main effect of group (F (1,33) = 27.00, p = 0.0001. Pairwise comparisons indicated that
patients made significantly faster first fixations to threatening images, (t(33) = 8.90, p = 0.0001, d = 0.7,
95% CI [−3.59, −1.76] compared to controls (patient M = 124.98 ms, SD = 65.67; control M = 210.24,
SD = 28.21) (Figure 5). The control group made significantly faster first fixations to the neutral stimuli
compared to the threatening, (t(16) = 3.97, p = 0.001, d = 1.02, 95% CI [0.28, 1.71]). In contrast, the pain
patients made significantly faster first fixations to the threatening image type compared to the neutral
image type (t(17) = 4.44, p = 0.0001, d = 0.9, 95% CI [−1.47, −0.27]). There was no significant main
effect of image type (F (1,33) = 5.36, p = 0.469).
300 **
**
250
**
First fixation time (ms)
200
150 Neutral
Threat
100
50
0
Patient Control
Figure 5. First fixation time (ms) (±SE) to threatening and neutral stimuli for the patient and control
group. ** indicates p < 0.01.
3.8. Dot Probe Response Time Measures

There was no significant interaction of group x attentional bias (F (1,33) = 3.17, p = 0.08), and no
significant main effect of group (F (1, 33) = 1.69, p = 0.20) or probe position (F (1, 33) = 4.60, p = 0.12).
There was no significant difference between attentional bias to threatening images for either congruent
(t(33) = 1.79, p = 0.08, d = 0.6, 95% CI [−3.35, 51.14]) or incongruent (t(33) = 0.47, p = 0.64, d = 0.6,
95% CI [−17.61, 28.29]) trials for the pain group (congruent, M= −14.23, SD ± 48.50 ms; incongruent,
M = 6.22, SD ± 39.46 ms) and controls (congruent, M = 9.66, SD ± 27.09 ms; incongruent, M = 11.56,
SD ± 25.32 ms). Table 2 shows the mean response times for the congruent, incongruent and neutral
trials for the chronic pain and control groups.
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Table 2. Mean reaction times of congruent and incongruent trials (in ms; standard deviations in
brackets) for the threat and neutral images in the dot probe task for participants with chronic low back
pain and the non-symptomatic control group.
Stimuli Chronic Pain Group Non-Symptomatic Control Group

Threat (ms) 595.79 (59.40) 548.74 (49.08)
Congruent
Neutral (ms) 591.32 (65.10) 540.44 (49.65)
Threat (ms) 597.31 (59.64) 552.69 (48.36)
Incongruent
Neutral (ms) 591.32 (65.10) 540.44 (49.65)
4. Discussion
This study used an eye gaze protocol to consider the attentional biases of individuals with chronic
back pain to threatening and neutral images using a modified dot probe paradigm. The eye gaze data
highlight important new findings about the differences in attentional bias to threatening and neutral
images between individuals with chronic pain and non-symptomatic controls that cannot be identified
by using the standard dot probe paradigm.
Within-group analysis demonstrated that the chronic pain individuals had a significantly higher
percentage of fixations, larger pupil diameter and longer average fixation duration on threatening
compared to neutral images. There were no significant differences in eye gaze metrics to threatening
or neutral images in non-symptomatic controls; the absence of attentional bias suggesting that
the back pain specific images were not perceived as threatening for the non-symptomatic controls.
Between-group analysis revealed that chronic pain participants also had a longer average fixation
duration and larger pupil diameter to threatening images compared to the non-symptomatic controls.
Chronic pain patients also had a faster initial fixation to the pain related image compared to the
neutral image; the opposite pattern was found for the non-symptomatic controls. In contrast, and of
concern to the validity of the standard dot probe procedure, there were no significant differences in
attentional biases for the dot probe task between the chronic pain group and non-symptomatic controls.
Taken together, the findings of this study suggest that eye gaze metrics may provide a more sensitive
measure of attentional bias compared to the dot probe response time.
The majority of previous research investigating pain-related attentional biases using eye gaze has
been within a non-symptomatic population and used word-based stimuli or pain-related faces [13–16].
To our knowledge, only three studies have previously used back pain-specific images in a dot
probe task [25–27], but none have used eye-tracking markers concurrent with the dot probe test
with pain-related physical activity movements. Consistent with the findings of Roelofs et al. [25]
the dot probe data indicated that there was no difference between chronic pain participants and
non-symptomatic controls for attention to threatening images in congruent trials. Whereas, the eye
gaze behavior in this study demonstrated that chronic pain participants attended to the pain-related
images significantly faster, more often and for a significantly longer average duration than neutral
images compared to non-symptomatic controls. The attentional bias to threatening stimuli in the
pain group may have been due to the implied motion cues within the image. Kourtzi et al. [9] found
greater activation of the medial temporal/medial superior temporal cortex (MT/MST) when viewing
photographs with implied movement and imaging studies have supported the role of these brain areas
in the analysis of movement, but not object, recognition [28]. Action understanding depends, in part,
on prior knowledge about the movement’s goal and intention with predictions about an object’s (or
body’s) future position being made from the motion implied in the static image [29]. Participant’s
memorial biases modulate the increase in attentional bias to threatening information and, therefore,
they perceive implied painful motion in the image (e.g., rotation of the back, which causes them pain);
the dynamic images accessing a more meaningful motor representation that is presented for analysis
through the variety of eye gaze metrics employed in this study.
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Eye tracking studies within healthy populations have identified vigilance towards pain-related
words and faces [14,15]. In line with previous research [18,19], we identified that chronic pain patients
attended to pain related images significantly faster than neutral images and in contrast to the profiles
of non-symptomatic controls. Todd et al. [5] have proposed the Threat Interpretation Model of pain
that can be used to consider some of the study’s findings. Specifically, there is an initial vigilance
towards the threat-related stimuli; as the threat continues, there is an avoidance of the threatening
cues. Further, Fashler and Katz [20] identified that both pain and control participants responded faster
to neutral images in the dot probe task, whereas the eye movement data demonstrated that in the early
phase of the trial, participants attended to the neutral images, then in the later phases, gaze duration
was maintained on the injury-related images. These findings are in contrast to those presented here;
there were no differences found for reaction time data and chronic pain patients only made faster first
fixations to pain related images. Due to the short presentation time used in this study, we were unable
to assess whether participants would maintain their gaze on the pain stimuli or, in line with Todd et
al., [5] the patients showed an active avoidance of the threatening cues. One possible explanation for
the differences could be due to the specificity of the images. Fashler and Katz [20] used images for
which both individuals with, and without pain could perceive as threatening (e.g., an open wound,
needle inserted into the skin etc.). In contrast, our study used images that were specific to back pain
and were not deemed threatening for the control group. Todd et al. [5] propose that initial vigilance
occurs when participants interpret the stimuli as threatening. The specificity of the image, and using a
homogenous pain group, may, therefore, have influenced the attentional bias to pain related stimuli.
Furthermore, the differences between the studies could be due to the image presentation time and type
of probe stimulus. In the current study, the images were presented for 500 ms and the dot probe was
either.. or : and each probe could appear on either side. In contrast, Fashler and Katz [20] presented
the images for 2000 ms and participants were shown a single dot, the response required participants to
press one of two buttons to indicate the side of the screen the dot was on. The significant differences in
the methods between the studies may explain the differences in the reaction time data. In contrast to
Fashler and Katz [20], Yang et al. [30] found that chronic pain participants had an early attentional
bias towards catastrophe-based words, followed by avoidance of pain words. Due to the short stimuli
presentation time within our study, we were only able to assess initial vigilance, consistent with
previous research in pain populations [18]. This bottom up process is considered to be automatic in
anxious individuals. In contrast to other studies identifying a vigilance-avoidance pattern [18,30], this
study used images of physical activity (rather than words) associated with pain. Images with implied
movement provide elements of action understanding. They may give more personal meaning, agency,
ownership and motor response [31] for the viewed activity for chronic back pain participants compared
to words, pain faces or images of an individual experiencing pain (e.g., someone grimacing while they
are completing an activity). Future studies should present pain-related images for a longer duration to
identify whether chronic back pain participants maintain vigilance or attend then avoid threatening
images. Using images that are specific to the pain condition may also provide researchers with the
ability to alter biases to allow for top down processing of attending to goal directed information.
This enhanced attention to goal related information may reduce avoidance of activity and disability
levels. Although a greater understanding of attention in this context is needed, preliminary evidence
has supported the therapeutic benefits of attentional bias modification in pain populations [32,33].
In this study, chronic pain participants showed a significantly larger pupil diameter to threatening
images compared to controls. As well as for light intensity, the pupil dilates under conditions of
high attentional allocation and also in response to emotionally-congruent information [34,35]. In this
regard, it has been suggested that pupil dilation is a physiological response that can indicate brain
mechanisms associated with the processing of emotional information [36]. When viewing threatening,
emotional images pupil dilation has also been found to be mediated by increased sympathetic activity
(e.g., increased heart rate and skin conductance) [34]. According to the biopsychosocial model of
pain [37], there is both a psychological and physiological response to pain. If individuals attend to
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their physiological reaction to emotional information, it increases their worry-based anxiety, based on
schemas, causing them to associate the increased arousal with the pain and lead to active avoidance
behaviors. The results from this study suggest that not only are individuals with chronic pain attending
to pain-related images more than controls, but they are also allocating greater visual attention to them
indicating that the stimuli having greater emotional congruence and meaning. This study suggests
that investigating pupil diameter could be a useful addition to the study of chronic pain.
The eye gaze data from this study provides support for current models of attention and extends
the current chronic pain literature. Models of attentional bias within chronic pain attribute slightly
different roles to the process of attention. In general, they propose that individuals in pain are fearful
of, and threatened by, pain [2,3,38], which causes them to over attend to pain-related information.
Pain is prioritized over other demands for attention [39], which interferes with movement, leads
to higher levels of anxiety, catastrophizing and ultimately exacerbation of levels of disability [40].
Understanding the mechanisms of attention to information which is perceived as threatening,
is essential to better understand approaches to effective intervention.
The longer duration of attention to pain-related images in this study may be a function of the
schemas associated with the movements. During experimental debriefs, some of the chronic pain
participants commented that the images they viewed reminded them of activities in which they
would expect to experience pain. Beck [41] proposed that maladaptive schemas cause individuals to
have a preoccupation with threatening information and subsequently catastrophize due to a negative
interpretive and attentional bias. Pincus and Morley [4] proposed the schema enmeshment model
of pain (SEMP) in an attempt to explain recall bias in chronic pain patients through the operation
of schemas. Pain schemas contain sensory, intensity, spatial and temporal features of pain, while
illness schemas contain information about the consequences of illness, and self-schemas contain
information about the self. The chronic pain experience may have illness related schemas about the
implications of self-future activity, which causes enmeshment with the pain sensory, self and illness
schemas. The anxiety experienced by the pain participants with particular activities they perceive as
pain threatening leads to different behavioral and cognitive reactions [1]. The misinterpretation of
pain stimuli leads to excessive fear of physical activity and avoidance of physical activity. This may be
due to their negative cognitions and increased somatic anxiety about completing the activity, which
leads to physical avoidance behavior [42]. Current interventions in the UK tend to focus on reducing
a patient’s disability through improved education about their pain and the opportunity to discuss
problems with particular activities [43]. Understanding the cognitive and emotional mechanisms
behind a patient’s initial activity avoidance behavior may allow for more specific interventions that
modify the way chronic pain patients not only attend to activity-related information, but also the way
they interpret the planned movement. The interaction of these two cognitive biases will affect the
processing of information, lead to behavior change and, potentially, reduce the patient’s disability.
There were some limitations in the study. First, the PHODA images used were not assessed for
their affective content (valence and arousal) or whether the images were personally meaningful to the
individual. The images have, however, been used successfully in previous dot probe studies and to
assess perceived harmfulness of daily activities [44,45] suggesting they have good ecological validity.
Although we did not ask chronic pain participants to rate the images directly, in follow up manipulation
checks, pain participants reported that they could attribute the images to behaviors in their daily life
and that the activities would be difficult and painful for them to complete at home. Similarly, verbal
follow up checks with the control group demonstrated that the PHODA images represented a “neutral”
image set and they showed no bias to either image type. Therefore, the biases predicted in the chronic
pain group can be attributed to the pain-specific content of the image set. Future studies should assess
the valence and arousal of the images in larger and more varied pain populations. Future research
should also consider asking patients to rate their personal relevance to them; there may be different
attentional biases towards images that are more personally-relevant, compared to those that are not
(e.g., see Lang’s meaning propositions within Bioinformational Theory [46]).
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J. Clin. Med. 2019, 8, 31
Due to the recruitment strategy, there may be some selection bias. It has been suggested that pain
patients who take part in research are often highly motivated, have more severe pain and respond
better to treatment [47]. This is a continuing issue for pain research. We were, however, interested
in the patients’ cognitive response to threatening stimuli and did not implement an intervention.
Future research may wish to consider comparing the health status of patients who volunteer, compared
to those who decline to take part in a study.
Although the power analysis indicated there was sufficient power for this study, the sample size
was low in comparison to other studies investigating attentional biases. Therefore, future research should
aim to include a larger sample size. It should be noted that although the use of eye gaze is regarded as a
more direct assessment of attention, it does not reflect overt attentional engagement. For example, visual
attention can occur in the absence of eye movements [48] and eye tracking technology does not measure
peripheral vision, which can be used to complete the dot-probe task accurately [17].
Despite these limitations, the present study provides further support for attentional biases towards
pain-related images in chronic back pain participants. This finding is supported by additional data from
eye gaze measurement techniques that provide a richer and more detailed analysis of the attentional
biases in this population. Future studies should be conducted which investigate whether images
that involve movement are more reliable at identifying attentional biases in chronic pain patients
compared to pain-related words within a dot probe paradigm. Future research should also investigate
the relationship between attention and interpretation of pain to provide an updated model to explain
the mechanisms associated with patient responses to chronic pain. If the cognitive mechanisms of
attention cause individuals with chronic pain to attend and dwell on painful stimuli, interventions that
focus on modifying a patient’s attention to goal-related outcomes (e.g., attentional bias modification)
may have important beneficial effects on future quality of life.
Author Contributions: Conceptualization, Z.C.F., P.S.H. and N.E.F.; Formal analysis, Z.C.F.; Investigation,
Z.C.F.; Methodology, Z.C.F., P.S.H. and N.E.F.; Project administration, Z.C.F.; Supervision, P.S.H. and N.E.F.;
Writing—original draft, Z.C.F., P.S.H. and N.E.F.; Writing—review & editing, Z.C.F. and P.S.H.
Acknowledgments: The authors would like to thank the physiotherapy and administration staff at Kingsgate
House in Stockport for their support throughout this project and allowing us to conduct this study in the clinic.
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Journal of
Clinical Medicine
Article
A Meta-Epidemiological Appraisal of the Effects of
Interdisciplinary Multimodal Pain Therapy Dosing
for Chronic Low Back Pain
Elena Dragioti 1, *, Mathilda Björk 1,2 , Britt Larsson 1 and Björn Gerdle 1
1 Pain and Rehabilitation Centre, and Department of Medical and Health Sciences, Linköping University,
SE-581 85 Linköping, Sweden; mathilda.bjork@liu.se (M.B.); britt.larsson@liu.se (B.L.);
bjorn.gerdle@liu.se (B.G.)
2 Division of Occupational Therapy, Department of Social and Welfare Studies, Faculty of Health Sciences,
Campus Norrkoping, Linköping University, SE-60174 Linköping, Sweden
* Correspondence: elena.dragioti@liu.se
Received: 21 May 2019; Accepted: 17 June 2019; Published: 18 June 2019
Abstract: Using a meta-analysis, meta-regression, and a meta-epidemiological approach,

we conducted a systematic review to examine the influence of interdisciplinary multimodal pain
therapy (IMPT) dosage on pain, disability, return to work, quality of life, depression, and anxiety in
published randomised controlled trials (RCTs) in patients with non-specific chronic low back pain
(CLBP). We considered all RCTs of IMPT from a Cochrane review and searched PubMed for additional
RCTs through 30 September 2018. A subgroup random-effects meta-analysis by length, contact,
and intensity of treatment was performed followed by a meta-regression analysis. Using random
and fixed-effect models and a summary relative odds ratio (ROR), we compared the effect sizes
(ES) from short-length, non-daily contact, and low-intensity RCTs with long-length, daily contact,
and high-intensity RCTs. Heterogeneity was quantified with the I2 metric. A total of 47 RCTs
were selected. Subgroup meta-analysis showed that there were larger ES for pain and disability
in RCTs with long-length, non-daily contact, and low intensity of treatment. Larger ES were also
observed for quality of life in RCTs with short-length, non-daily contact, and low intensity treatment.
However, these findings were not confirmed by the meta-regression analysis. Likewise, the summary
RORs were not significant, indicating that the length, contact, and intensity of treatment did not have
an overall effect on the investigated outcomes. For the outcomes investigated here, IMPT dosage is
not generally associated with better ES, and an optimal dosage was not determined.
Keywords: programme dosage; interdisciplinary multimodal pain therapy; pain rehabilitation;

low back pain; meta-analysis
1. Introduction
Currently, interdisciplinary multimodal pain therapy (IMPT) is used as a first-line therapy
for chronic low back pain (CLBP) management [1–4]. IMPT, a long biopsychosocial treatment
framework provided by a team of professionals, generally contains a synchronised combination of
physical, educational, or psychological treatments in combination with measures for returning to
work/studies [5,6]. Because IMPT can effectively treat patients with non-specific CLBP, it is strongly
recommended [1–4]. Compared to usual care or physical treatment, IMPT has a consistent positive
effect on disability and pain according to systematic reviews (SRs) [2,4]. In a new umbrella review,
our team found suggestive evidence that IMPT might improve the likelihood of returning to work [5].
In addition, IMPT might decrease the personal and economic burden and increase the patients’
treatment participation [2,7].

J. Clin. Med. 2019, 8, 871
However, IMPT treatments are rather costly. The costs mainly depend on the treatment dosage,
which includes the total duration, the contact (daily or non-daily), and intensity of treatment
(number of contact hours per week) [8–10]. In addition, IMPT costs increase as the duration, contact,
and intensity of treatment increase [8–10], and IMPT heavily depends on the involved professions.
Typically, IMPT includes costs for physical therapists, psychologists, occupational therapists, physicians,
and administration personnel [11]. Additionally, concerns include the costs of attending such treatments
and the large societal costs of those patients who do not complete the treatments and do not return to
work [11]. Therefore, the dosage of the treatment and the multidisciplinary nature of IMPT provide
relatively high direct costs for both patients and the healthcare system [11]. Hence, variances in the
IMPT dosage may lead to differences in both effectiveness and costs [8–10].
Presently, the optimal IMPT dosage and which dosage is efficacious for the patients with
non-specific CLBP is unidentified [9], despite the need for a standardisation of such treatments [5,12].
A recent systematic review showed that IMPT dosage was never studied as a primary outcome, and its
optimum dosage is currently unknown [10]. Our umbrella review also showed that a short duration of
IMPT for CLBP patients with short-term and medium-term pain had the largest evidence of returning
to work (highly suggestive evidence and suggestive evidence, respectively) [5]. A better understanding
of how IMPT dosage is associated with outcome effects (e.g., pain, disability, and work status) should
be considered when determining dosage. In turn, this could lead to better and more efficient patient
care, which will benefit patients, rehabilitation facilities, insurers, and employers [8,11].
Here, we conducted a systematic review with meta-analysis and a meta-epidemiological
appraisal to examine whether IMPT dosage is associated with better outcome effects in patients
with non-specific CLBP.

This study was designed based on the Preferred Reporting Items for Systematic Reviews and
Meta-Analyses (PRISMA) guidelines [13,14]. Because this meta-research project did not require patients
to be directly involved, ethical approval was not required.
2.1. Literature Search and Study Selection

This study includes all randomised controlled trials (RCTs) included in Kamper et al.’s Cochrane
systematic review [2]. We choose this review because it is the most recent and comprehensive review
with the largest number of included RCTs. We also searched PubMed through 30 September 2018 for
additional fully published RCTs in peer-reviewed journals investigating the effectiveness of IMPT
on non-specific CLBP. The basic search strategy included the following key terms: chronic low back
pain, interdisciplinary, multimodal pain therapy, multidisciplinary biopsychosocial rehabilitation,
and randomised controlled trials (for details, see Box S1, Supplementary Materials).
We included only RCTs that (1) examined any IMPT versus any control (e.g., treatment as usual,
and waiting list) or other treatment (e.g., physiotherapy and surgery), (2) included only adult men
and women, (3) identified a diagnosis of a non-specific CLBP lasting more than three months, and (4)
published in English expect for those included in the Kamper et al.’s review [2] as the provided data in
this study were already translated into English.
We excluded studies if they (1) used a study design other than RCT, (2) compared different
IMPTs with each other (i.e., head-to-head comparisons), (3) included participants with fewer than 50%
diagnosed with non-specific CLBP, (4) included a diagnosis of LBP due to cancer, infection, inflammatory
arthropathy, osteoporosis, high-velocity trauma, fracture, pregnancy, rheumatoid arthritis, or rheumatic
pain, and (5) provided insufficient or inadequate data for quantitative synthesis.
2.2. Data Extraction

One investigator (E.D.) screened titles and abstracts, assessed the eligibility, extracted data,
and rated the quality of the included RCTs. These were also checked by a second author (M.B.).
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J. Clin. Med. 2019, 8, 871
Any disagreements were resolved by consensus, or a third reviewer (B.G.) was consulted if
disagreements persisted. The six primary outcomes of interest for this study were pain, disability,
work status (return to work), quality of life, depression, and anxiety as reported by the original authors
of the RCTs. We chose these outcomes because these were the most common outcomes in RCTs with
adequate data for analysis. Other outcomes (e.g., fear avoidance and coping strategies) provided
limited data for synthesis. Because of the same limitation (i.e., limited data for adequate synthesis),
we also focused only on short-term outcomes (i.e., up to three months). The IMPT dosage was defined
according to total duration (in weeks), daily contact or non-daily contact, and intensity of treatment
(number of contact hours per week) [2,10].
2.3. Assessment of Bias

We used the updated Cochrane Back Review Group criteria [15] to rate the quality of the included
RCTs, which include 12 criteria and assess the risk of bias (RoB). For each criterion, the quality
of each RCT was classified as high (i.e., low RoB = 1), moderate (i.e., unclear RoB = 2), and low
(i.e., high RoB = 3). Next, we evaluated an overall “risk of bias” assessment for each RCT by giving
one point to each criterion when low RoB was indicated. Thus, RCTs satisfying at least six of the 12
criteria and having no having no serious flaws (e.g., 80% drop-out rate in one group) were considered
as “low” risk of bias [15]. RCTs with serious flaws, or those in which fewer than six of the criteria are
met were considered as having a “high” risk of bias [15]. It is important to note that the blinding is
quite problematic in this field [2,10].
2.4. Data Synthesis and Analysis

We analysed data descriptively and conducted subgroup meta-analysis of all the outcomes of
interest as listed above. Specifically, to explore the effects of IMPT dosage—i.e., the total duration
(in weeks), the contact, and intensity of treatment (number of contact hours per week)—a series of
random-effects meta-analyses [16] were conducted by clustering the RCTs according to the following
variables: short length (in weeks; <5 weeks) vs. long length (≥5 weeks); non-daily contact vs. daily
contact; and low intensity vs. high intensity (e.g., less than 30 h per week vs. more 30 h per week).
Dichotomous outcomes were analysed by calculating the pooled odds ratio (OR), and continuous
outcomes were analysed by calculating the standardised mean difference (SMD). Between-study
heterogeneity was evaluated by Cochran’s Q test [16] and quantified with the I2 metric of inconsistency
(low, moderate, large, and very large for values of <25, 25–49, 50–74, and >75%, respectively) [17,18].
We also calculated the 95% confidence intervals for the I2 . We used the regression asymmetry test
and funnel plots to estimate publication bias for all outcomes of interest [19]. We also performed
a random-effects meta-regression analysis [20] to examine the potential moderator effect of dosage
aspects, mean age of the participants, gender (female), type of control (i.e., physical activity), and RoB
assessment (i.e., RCTs with low risk as previously described) on treatment effects. The dosage aspects
(duration and intensity) were included in the meta-regression analysis as continuous variables for a
more accurate estimation [20]. The only exception was for contact since it was only in binary form.
To further systemically assess the potential influence of IMPT dosage on the outcomes of interest,
we used a meta-epidemiological approach [21–23] comparing the magnitude of the effect size (ES) by
the treatment dosage in terms of the total duration (in weeks), the contact, and intensity of treatment
(number of contact hours per week) for each outcome. To match the outcome data and allow for the
synthesis of the evidence, we transformed the SMD to a logOR for the continuous outcomes [22] based
on a standardised formula [24].
From each outcome, we calculated a summary OR for the short-duration RCTs and long-duration
RCTs, for the non-daily contact and daily contact, and for the low-intensity vs. high-intensity RCTs
within the eligible RCTs using fixed-effect models [22,25]. This method is more proper for examining
study design factors on treatment effects [21–23]. All comparisons were coined so that the experimental
arm was always an IMPT vs. a control arm. Next, we obtained a relative OR (ROR) within all
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J. Clin. Med. 2019, 8, 871
comparisons for each outcome [22]. A ROR that exceeds 1 equates to assessments providing a more
favourable response to the experimental IMPT supported by an RCT with long duration, daily contact,
and high intensity compared to RCTs with short duration, non-daily contact, and low intensity.
To obtain a summary ROR (sROR) across all outcomes, we combined the natural logarithm estimates
of the RORs for all comparisons [21] using fixed- and random-effects models [16,25].
The statistical analyses were made using STATA version 10.0 (STATA Corp, College Station, Texas,
USA); a value of p < 0.05 (two-tailed) was set as the level of significance.
3. Results
We identified 41 RCTs from Kamper et al.’s study [2]. The electronic search yielded a total
of 3799 potentially eligible titles. Following the search and screening and retrieval of 126 full text
articles, six additional RCTs were determined to be eligible (Figure S1, Supplementary Materials).
These articles were added to the 41 RCTs included in Kamper et al. [2] to make a total of 47 included
RCTs (see Supplementary Materials for the list of refences of the included studies). The two independent
investigators reached a very high level of agreement (43/47 RCTs). In the whole process, from screening
to data extraction, any disagreement was discussed with a third researcher (B.G.) until a consensus
was reached.
3.1. Characteristics of Included Studies

Table 1 presents the characteristics of studies. All the 47 included studies were RCTs published
from 1990 to 2017. Most studies were conducted in Europe (n = 34; 74%). The number of participants
ranged from 20 to 542 with a median number of 134 participants per study (interquartile range
(IQR = 84–195), a median age of 44 years old (IQR = 41–47), a total treatment duration ranging from
1–16 weeks with a median of five weeks (IQR = 3–7), and a number of contact hours (per week) ranging
from 1–100 h (median = 10; IQR = 3–30). Most RCTs provided a non-daily contact (n = 26; 56%).
Although the definition of CLBP varied among studies, most studies defined CLBP as back pain lasting
more than three months (Table 1). The number of datasets included in the meta-analysis per outcome
varied from two (anxiety) to 28 (pain).
268
Table 1. Characteristics of included studies.
Mean Age Total Contact

Definition of RoB
Author, Year * Country Sample Size Female % (or Age Treatment Control Duration Contact Duration
Chronic LBP Assessment
Range) (Weeks) (h/Week)
Abbassi, 2012 Iran 33 88 45 IMPT TAU LBP >6 months 7 Non-daily contact 4 Low risk
Alaranta, 1994 Finland 293 56 41 IMPT Physical LBP >6 months 6 Daily contact 100 High risk
Altmaier, 1992 USA 45 73 40 IMPT Physical LBP >3 months 3 Daily contact 20 High risk
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Basler 1997 Germany 76 76 49 IMPT TAU LBP >6 months 12 Non-daily contact 2.5 High risk
Bendix, 1996/1998 Denmark 106 70 40 IMPT TAU LBP >6 months 3 Daily contact 49 High risk
Bendix, 1995/1998 Denmark 106 75 42 IMPT Physical LBP >6 months 4 Daily contact 45 High risk
Bendix, 2000 Denmark 138 65 41 IMPT Physical LBP >6 months 4 Daily contact 45 High risk
Coole, 2013 UK 51 53 44 IMPT Physical LBP >3 months 16 Non-daily contact 3 High risk
Corey, 1996 Canada 138 NR NR IMPT TAU LBP >3 months 5 Daily contact 32.5 High risk
Fairbank, 2005 UK 349 51 18–55 IMPT Surgery LBP >1 year 3 Daily contact 75 Low risk
Harkapaa, 1989 Finland 309 37 45 IMPT Physical LBP for >2 years 3 Daily contact 100 High risk
Hellum, 2011 Norway 173 51 41 IMPT Surgery LBP >1 year 5 Non-daily contact 12 High risk
Henchoz, 2010 Switzerland 109 32 40 IMPT Physical LBP >3 months 3 Non-daily contact 30 High risk
Jackel, 1990 Germany 71 62 49 IMPT WL LBP >3 months 6 Daily contact 36 High risk
Jousset, 2004 France 84 33 40 IMPT Physical LBP >3 months 5 Daily contact 30 High risk
Kaapa, 2006 Finland 120 100 46 IMPT Physical LBP >1 year 7 Daily contact 100 Low risk
Kole-Snijders, 1999 Netherlands 148 64 40 IMPT WL LBP >6 months 8 Daily contact 13 High risk
Kool, 2007 Switzerland 174 21 42 IMPT Physical LBP >3 months 3 Non-daily contact 24 Low risk
Lambeek, 2010 Netherlands 134 42 18–65 IMPT TAU LBP >3 months 12 Non-daily contact 3 Low risk
269
Leeuw, 2008 Netherlands 85 48 45 IMPT IMPT LBP >3 months 16 Non-daily contact 2 Low risk
Linton, 2005 Sweden 185 83 49 IMPT TAU NR 6 Non-daily contact 2 High risk
Lukinmaa, 1989 Finland 158 53 44 IMPT TAU NR 1 Non-daily contact 2.5 High risk
Mangels, 2009 Germany 363 78 49 IMPT Physical ICD 10 4 Daily contact 100 Low risk
Meng, 2011 Germany 360 64 49 IMPT TAU/IMPT ICD 10 7 Non-daily contact 1 High risk
Mitchell, 1994 Canada 542 29 nr IMPT TAU NR 8 Daily contact 35 High risk
Moix, 2003 Spain 30 53 54 IMPT TAU NR 11 Non-daily contact 1 High risk
Monticone, 2013 Italy 90 58 50 IMPT TAU LBP >3 months 5 Non-daily contact 3 Low risk
Monticone, 2014 Italy 20 NR NR IMPT Physical LBP >3 months 8 Non-daily contact 3 Low risk
Table 1. Cont.
Mean Age Total Contact

Definition of RoB
Author, Year * Country Sample Size Female % (or Age Treatment Control Duration Contact Duration
Chronic LBP Assessment
Range) (Weeks) (h/Week)
Morone, 2011 Italy 73 64 60 IMPT TAU LBP >3 months 4 Non-daily contact 4 High risk
TAU/
Morone, 2012 Italy 75 72 55 IMPT LBP >3 months 4 Non-daily contact 4 High risk
Physical
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Nicholas, 1991 Australia 58 52 41 IMPT Physical LBP >6 months 5 Non-daily contact 3.5 High risk
Nicholas, 1992 Australia 20 45 44 IMPT Physical LBP >6 months 5 Non-daily contact 3.5 High risk
Roche, 2007/2011 France 132 35 40 IMPT Physical LBP >3 months 5 Daily contact 30 Low risk
Smeets, 2006/2008 Netherlands 212 42 47 IMPT WL LBP >3 months 10 Non-daily contact 7.1 Low risk
Skouen, 2002 Norway 195 44 43 IMPT TAU/IMPT NR 4 Daily contact 30 High risk
Schweikert, 2006 Germany 409 17 47 IMPT Physical LBP >6 months 3 Daily contact 17.5 High risk
Strand, 2001 Norway 117 61 43 IMPT TAU ICPC diagnosis 5 Daily contact 30 High risk
Streibelt, 2009 Germany 222 17 46 IMPT Physical NR 3 Non-daily contact 20 High risk
Tavafian, 2008 Iran 102 100 43 IMPT TAU LBP >3 months 1 Non-daily contact 5 High risk
Tavafian, 2011 Iran 197 22 45 IMPT TAU LBP >3 months 1 Non-daily contact 10 Low risk
Tavafian, 2014 Iran 178 75 44 IMPT TAU LBP >3 months 1 Daily contact 5 High risk
Tavafian 2017 Iran 146 78 46 IMPT TAU LBP >3 months 1 Daily contact 5 Low risk
Tavafian, 2017 Iran 165 79 45 IMPT TAU LBP >3 months 1 Daily contact 5 Low risk
Physical/
Turner, 1990 USA 96 49 44 IMPT LBP >6 months 8 Non-daily contact 2 High risk
WL
Van den Hout, 2003 Netherlands 84 34 40 IMPT IMPT LBP >6 months 8 Non-daily contact 20 High risk
270
Vollenbroek-Hutten,
Netherlands 163 NR 39 IMPT TAU LBP >6 months 7 Non-daily contact 9 Low risk
2004
score >7/23 on
Von Korff, 2005 USA 240 63 50 IMPT TAU 1 Non-daily contact 3 High risk
RMDQ
* See references of included randomised controlled trials (RCTs) 1–47 in Supplementary Materials; ICD 10—International Statistical Classification of Diseases and Related Health Problems,
Tenth Revision, ICPC—International Classification of Primary Care, LBP—lower back pain, IMPT—interdisciplinary multimodal pain therapy, NR—not reported, RMDQ—Roland
Morris Disability Questionnaire, RoB—risk of bias, TAU—treatment as usual, UK—United Kingdom, USA—United States of America, WL—waiting list.
J. Clin. Med. 2019, 8, 871
3.2. Risk of Bias in Included Studies

The results of the RoB assessment are presented in Table S1 (Supplementary Materials). Overall,
15 of the 47 studies (32%) were evaluated as low risk of bias. The most important methodological flaws
were related to a lack of participant, clinician, and outcome assessment blinding; in particular, 46 out
of 47 RCTs (almost 100%) had a high risk of bias in all three of these criteria (Figure 1). However, as in
any psychotherapy [22], blinding is not possible, at least to participants or clinicians, in this type of
treatment [2,10].
Figure 1. Risk of bias graph: assessments for seven risk of bias criteria presented as percentages across
all included studies.
3.3. Publication Bias

Publication bias was observed for three outcomes (disability (p = 0.018), quality of life (p = 0.060),
and depression (p = 0.081)), based on the funnel plots and Egger’s regression test (see Figures S2–S6,
Supplementary Materials). No publication bias remained for the outcome of pain (p = 0.219) after
excluding the study of Monticone et al. (2013) (Reference 27 in Supplementary Materials) providing a
large outlier as seen in Figure S2 (Supplementary Materials). Publication bias for anxiety outcome
could not be estimated due to the inadequate number of included studies (only two RCTs).
3.4. Analyses for Outcomes of Interdisciplinary Multimodal Pain Therapy (IMPT) by Length, Contact, and Intensity
For each outcome, subgroup analysis was conducted for IMPT dosage by length, contact, and
intensity (Table 2). There were larger ES for pain and disability in RCTs with long length, non-daily
contact, and low intensity of treatment. Larger and significant ES were also observed for quality of
life in RCTs with short length, non-daily contact, and low intensity of treatment. After excluding
the study of Moticone et al. (2013/2014) (References 27,28 in Supplementary Materials), the ES were
similar between the aspects of dosage for the outcomes of pain and disability (see Figures S7–S12,
Supplementary Materials). The forest plots of the overall ES from all studies included for the six
outcomes per RoB assessment, type of control, and aspects of dosage are provided in Figures S13–S18
(Supplementary Materials).
271
Table 2. Characteristics and subgroup meta-analysis for dose of IMPT by length, contact, and intensity of the six investigated outcomes.
Average Total Average Level of Active (i.e.,

Level of Level of Low I2
Duration h/Week Physical)/Non-Active Overall ES (95% CI)
Short-Term Outcomes No. of RCTs Daily/Non-Daily Risk/High Risk p-Value (%; 95% CI)
(Median Weeks, (Median, Control (i.e., Random-Effects Model
Contact (n) of Bias (n) p-Value
IQR) IQR) WL/TAU) (n)
Outcome 1: Pain
Length
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Short length (<5 weeks) 12 3 (1–4) 7.5 (4–22) 8/4 6/6 3/9 SMD, −0.33 (−0.55 to −0.11) 0.003 81 (67–88) 0.000
Long length (≥5 weeks) 16 8 (5.5–10) 3.5 (2.7–10) 4/12 8/8 8/8 SMD, −0.45 (−0.73 to −0.17) 0.001 79 (64–85) 0.000
Contact
Non-daily contact 16 7.5 (4.5–10) 3.3 (2.7–4) 0/16 7/9 6/10 SMD, −0.50 (−0.79 to −0.20) 0.001 80 (67–86) 0.000
Daily contact 12 3 (2–5.5) 22 (11.5–68) 12/0 7/5 5/7 SMD, -0.29 (−0.49 to −0.09) 0.005 78 (59–86) 0.000
Intensity
<30 h per week 23 5 (3–8) 4 (3–7.1) 7/16 10/13 8/15 SMD, −0.42 (−0.62 to −0.20) <0.000 81 (71–86) 0.000
>30 h per week 5 5 (4–6) 100 (36–100) 5/0 4/1 3/2 SMD, −0.32 (−0.63 to −0.05) 0.022 79 (31–89) 0.001
Outcome 2: Disability
Length
Short length (<5 weeks) 10 3 (1–4) 7.5 (4–30) 5/5 5/5 2/8 SMD, −0.27 (−0.48 to −0.07) 0.007 75 (47–85) 0.000
Long length (≥5 weeks) 17 7 (6–10) 3.5 (3–9) 4/13 9/8 9/8 SMD, −0.51 (−0.78 to −0.24) <0.000 82 (73–88) 0.000
272
Contact
Non-daily contact 18 7 (4–10) 3.5 (3–4) 0/18 8/10 7/11 SMD, −0.58 (−0.86 to −0.31) <0.000 81 (70–87) 0.000
Daily contact 9 4 (1–3) 36 (18–100) 9/0 6/3 4/5 SMD, −0.16 (−0.33–0.01) 0.055 67 (16–82) 0.002
Intensity
<30 h per week 20 6 (4–9) 3.8 (3–6) 3/17 8/12 8/12 SMD, −0.49 (−0.74 to −0.24) <0.000 85 (78–89) 0.000
>30 h per week 7 5 (3–6) 100 (30–100) 6/1 6/1 3/4 SMD, −0.26 (−0.43 to −0.09) 0.003 54 (0–78) 0.043
Table 2. Cont.

Outcome 3: Return to
work
J. Clin. Med. 2019, 8, 871
Length
Short length (<5 weeks) 3 3 (1–4) 24 (3–30) 2/1 1/2 1/2 OR, 1.46 (0.82–2.62) 0.199 42 (0–83) 0.177
Long length (≥5 weeks) 2 5 (5–5) 30 (30–30) 2/0 2/0 1/1 OR, 1.10 (0.55–2.20) 0.786 0 (NA) # 0.938
Contact
Non-daily contact 1 1 (1–1) 3 (3–3) 0/1 0/1 0/1 OR, 0.91 (0.31–2.68) 0.864 NA
Daily contact 4 4.5 (3.5–5) 30 (27–30) 4/0 1/3 2/2 OR, 1.46 (0.96–2.21) 0.075 12 (0–72) 0.332
Intensity
<30 h per week 2 2 (1–3) 13.5 (3–24) 1/1 1/1 1/1 OR, 1.63 (0.65–4.09) 0.297 56 (NA) # 0.133
>30 h per week 3 5 (4–5) 30 (30–30) 3/0 2/1 1/2 OR, 1.12 (0.69–1.82) 0.645 0 (0–73) 0.994
Outcome 4: Quality of
life
Length
273
Short length (<5 weeks) 8 1.5 (1–3.5) 7.5 (4–13.7) 5/3 3/5 2/6 SMD, 0.49 (0.14–0.84) 0.006 83 (65–90) 0.000
Long length (≥5 weeks) 1 10 (10–10) 7.1 (7.1–7.1) 0/1 1/0 1/0 SMD, 0.14 (−0.24–0.52) 0.470 NA
Contact
Non-daily contact 4 4 (1–10) 4 (3–7.1) 0/4 2/2 2/2 SMD, 0.53 (0.09–0.98) 0.019 64 (0–86) 0.038
Daily contact 5 1.5 (1–3) 10 (5–18) 5/0 2/3 1/4 SMD, 0.38 (−0.06–0.81) 0.089 88 (70–93) 0.000
Intensity
<30 h per week 8 2 (1–4)) 6 (4–10) 4/4 3/5 2/6 SMD, 0.54 (0.25–0.83) <0.000 75 (38–86) 0.000
>30 h per week 1 2 (2–2) 100 (100–100) 1/0 1/0 1/0 SMD, −0.38 (−0.74 to −0.02) 0.041 * NA
Table 2. Cont.

Outcome 5: Depression
Length
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58.8
Short length (<5 weeks) 2 3.5 (3–4) 2/0 2/0 1/1 SMD, 0.08 (−0.22–0.39) 0.584 71 (NA)# 0.063
(17.5–100)
Long length (≥5 weeks) 8 7.5 (5.5–9) 5.3 (2.8–21.5) 2/6 5/3 3/5 SMD, −0.09 (−0.29–0.11) 0.358 20 (0–64) 0.273
Contact
Non-daily contact 6 8 (5–10) 3.5 (2–7.1) 0/6 4/2 2/4 SMD, 0.01 (−0.21–0.22) 0.959 0 (0–61) 0.562
Daily contact 4 5 (3.5–6.5) 68 (26.8–100) 4/0 3/1 2/2 SMD, −0.07 (−0.35–0.22) 0.653 72 (0–88) 0.013
Intensity
<30 h per week 7 8 (5–10) 7.1 (2–17.5) 2/5 4/3 2/5 SMD, 0.12 (−0.03–0.27) 0.119 1 (0–59) 0.414
>30 h per week 3 5 (4–7) 100 (3.5–100) 2/1 3/0 2/1 SMD, −0.18 (−0.46–0.10) 0.202 46 (0–84) 0.155
Outcome 6: Anxiety
Length
17.5
Short length (<5 weeks) 1 3 (3–3) 1/0 1/0 0/1 SMD, 0.08 (−0.13–0.29) 0.455 NA
274
(17.5–17.5)
Long length (≥5 weeks) 1 5 (5–5) 3.5 (3.5–3.5) 0/1 1/0 0/1 SMD, −0.58 (−1.48–0.32) 0.209 NA
Contact
Non-daily contact 1 5 (5–5) 3.5 (3.5–3.5) 0/1 1/0 0/1 SMD, −0.58 (−1.48–0.32) 0.209 NA
17.5
Daily contact 1 3 (3–3) 1/0 1/0 0/1 SMD, 0.08 (−0.13–0.29) 0.455 NA
(17.5–17.5)
Intensity
10.5
<30 h per week 2 4 (3–5) 1/1 2/0 0/2 SMD, −0.10 (−0.67–0.48) 0.740 48 (NA) # 0.164
(3.5–17.5)
>30 h per week 0 0 (0–0) 0 (0–0) 0/0 0/0 0/0 NA NA NA
Notes: * favours control, # degrees of freedom (df n − 1) must be at least 2, CI—confidence interval, ES—effect size, OR—odds ratio, I2 —I square metric of heterogeneity, IQR—interquartile
range, TAU—treatment as usual, SMD—standardised mean difference, NA—not applicable, WL—waiting list.
J. Clin. Med. 2019, 8, 871
3.5. Meta-Regression
In the meta-regression analyses, none of the examined variables displayed a moderating effect
on the five examined outcomes (i.e., pain, disability, return to work, quality of life, and depression).
For the anxiety outcome, there were insufficient observations to perform such analysis (Table S2,
Supplementary Materials).
3.6. Comparison of Relative Odds Ratios

The comparison of RORs by length of treatment showed that, for pain and disability, the summary
RORs were >1, demonstrating that the IMPT was more favourable in RCTs with long length of
treatment (i.e., RCTs with duration of more than five weeks). However, the summary ROR was not
significant (sROR = 1.48 (95% confidence interval (CI) 0.78–2.81, p = 0.232) using the random-effects
model, showing that the length of treatment did not have an overall effect on the investigated outcomes
(Figure 2). Very large heterogeneity was observed (I2 = 82%, 95% CI 55–90%). Under the fixed-effect
models the sROR was, however, significant (Figure S19, Supplementary Materials).
Figure 2. The relative odds ratios (RORs) and 95% confidence intervals (CIs) for each outcome, and the
summary RORs and their 95% CIs at short term of a short-length treatment vs. long-length treatment.
The RORs were calculated with a random-effects model. A ROR >1 favours long length; an ROR <1
favours short length.
The comparison of RORs by contact of treatment (i.e., non-daily contact vs. daily contact) showed
that the summary ROR was <1 only for disability, a finding that indicates that the IMPT was more
favourable in RCTs with non-daily contact of treatment (i.e., RCTs with at least 3 h per week). However,
the summary ROR was not significant (sROR = 0.56; 95% CI 0.22–1.44; p = 0.230) according to the
random-effects model (Figure 3), showing that the contact of treatment did not have an overall effect on
the investigated outcomes, whereas the sROR was significant under the fixed-effect models (Figure S20,
Supplementary Materials). Very large heterogeneity was also present (I2 = 93%, 95% CI 88–95%).
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Figure 3. The relative odds ratios (RORs) and 95% confidence intervals (CIs) for each outcome, and
the summary RORs and their 95% CIs at short term of non-daily contact vs. daily contact. The RORs
were calculated with a random-effects model. A ROR >1 favours daily contact; an ROR <1 favours
non-daily contact.
With respect to the intensity of treatment (i.e., low intensity vs. high intensity), the summary
ROR was <1 only for disability, demonstrating that the IMPT was more favourable in RCTs with low
intensity of treatment (i.e., RCTs with less than 30 h per week). The summary ROR was also not
significant (sROR = 1.12; 95% CI 0.66–1.89; p = 0.672) using the random-effects model, showing that
the intensity of treatment did not have an overall effect on the outcomes. Large heterogeneity was
observed (I2 = 70%, 95% CI 21–87%) (Figure 4). Similar results were evident when the fixed-effect
models were used (Figure S21, Supplementary Materials). A sensitivity analysis excluding the study
of Moticone et al. (2013/2014) (References 27,28 in Supplementary Materials) did not alter the overall
effects between the comparison of RORs (Figures S22–S24, Supplementary Materials).
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Figure 4. The relative odds ratios (RORs) and 95% confidence intervals (CIs) for each outcome, and
the summary RORs and their 95% CIs at short term of low intensity vs. high intensity. The RORs
were calculated with a random-effects model. A ROR >1 favours high intensity (i.e. >30 h per week);
an ROR <1 favours low intensity (i.e. <30 h per week).
4. Discussion
When evaluating the 47 RCTs of IMPT by length, contact, and intensity, we found that IMPT
dosage did not have an overall influence on the reported effects in patients with non-specific CLBP.
Specifically, the summary RORs were not significant when we compared the effect estimates for
the investigated outcomes from the short-length and the long-length treatments and the non-daily
contact with the daily contact. There was no significant influence for either intensity of the treatment.
Although we found large heterogeneity between RCTs, the meta-regression analysis revealed that none
of the examined factors were potential factors for heterogeneity.
Yet, per individual outcome, some evidence exhibited that IMPT of more than five weeks may be
related to more “favourable” effects for pain reduction, while a long treatment with non-daily contact
and low intensity may be associated with more beneficial effects for disability. These results were
supported by both subgroup meta-analyses and meta-analytical comparisons of RORs between the
treatment effects. This study suggests that an optimal IMPT dosage from the published work is not
possible to be standardised. This finding partly agrees with the idea that the published recommended
IMPT dosages are somewhat arbitrary and primarily based on clinical expertise and experience [8].
Our study, however, did not confirm an overall IMPT dose–treatment–effect association in agreement
with a recently published non-inferiority RCT [9].
To our knowledge, this is the first study to examine the influence of IMPT dosage in such a
systematic appraisal followed by meta-analysis and meta-epidemiological approach across the largest
dataset of published RCTs, calculating the magnitude of the observed effect. Our meta-epidemiological
approach with comparison of RORs is suitable for examining study design factors and characteristics
on treatment effects [21–23]. IMPT, a complex treatment, requires a broad set-up of outcome variables.
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The present review had such a broad approach when evaluating IMPT dosage. Hence, we analysed
dosage aspects for the individual outcomes and used a more comprehensive approach—the summary
estimates of outcomes. Although IMPT dosing is rather essential in terms both of efficacy and healthcare
costs [8,11], it was not systematically and thoroughly assessed in RCTs [9]. Few other studies that
focused on IMPT dosage and these studies included a smaller number of RCTs or used different
methodological methods and outcomes [4,10]. In a Cochrane review, Guzman et al. compared 12 IMPTs
in 1964 patients with CLBP [4]. Their meta-analysis found that daily intensive IMPT (with more
than 100 h per week) with respect to disability was more beneficial than monodisciplinary treatment.
Evidence regarding other outcomes was either limited or ambivalent [4]. However, their review was
not designed to directly study the influence of treatment dosage on outcome effects.
Waterschoot et al. conducted a systematic review analysing the influence of IMPT dosage on
disability, work, and quality of life in patients with CLBP and included 18 studies [10]. As in our
study, the studies included in that review varied in terms of dosage (total duration and contact
hours) and outcome effects. Their linear mixed-effect modelling showed that duration in weeks was
significantly associated with the aforesaid outcomes [10]. It was somewhat surprising that we did
not find an association between duration of treatment (or any other dose aspect) and effects on pain,
disability, return to work, quality of life, depression, or anxiety. An explanation could be that different
components such as a professional’s expertise or different types of professionals involved in an IMPT
might have greater influence than the dosage variables. Waterschoot et al. also suggested that the
content of such treatments is strongly related to dosage aspects; thus, the independent effect of dosage
is not easily detectable [10]. A final explanation of the lack of association between and outcome effects
is that there is also the possibility that the dosage does not actually influence the outcomes in this
target group. The latter is supported by the subgroup analysis in Kamper et al. as they found that
there was no pattern of smaller or larger effects for duration and contact with IMPT while the intensity
of treatment slightly affected the treatment effects [2]. This finding is also supported by Reneman et al.
who found that the dosage is not related to differences in disability [9].
One limitation of our study is that we did not explore the potential interaction of the role of
professionals per RCT with length, contact, and intensity of treatment. Also, the individual components
of IMPT may differ between RCTs without any difference in the overall dosage variables investigated
here. Moreover, it is possible that some professionals might be unequally trained or have less clinical
expertise for the application of the multidisciplinary treatment, and it might be hypothesised that
these factors could affect the exact extent/dosage of a program. For example, well-trained professionals
with extensive clinical expertise might require fewer contacts to help their patients. A related issue is
the adherence to the treatment protocols within IMPT by the professionals. Many treatments require
that the patients apply the achieved insights and knowledge in their home environments or jobs,
and the time spent on this is usually not included in the stated doses. Furthermore, the severity of
the clinical presentations of the patient groups, as well as the social context (e.g., with respect to the
insurance situation) may differ substantially between RCTs; unfortunately, there are no established
and standardised ways to compare chronic pain patient cohorts. It is also possible that the diversity of
the professionals and the multidisciplinary nature of the treatment per se may lead to differences in
treatment effects in relation to the variation of dosage [8,11]. However, there are no related data in the
literature to either support or reject this hypothesis. Another limitation is that the dichotomisation
between length was based on the median value of the total duration of the IMPT per week; thus, one
may argue that this was somewhat subjective. However, in the literature, there is not a valid cut-off
score to precisely define what is a short-length or long-length treatment, although the categorisation of
contact and intensity was based on the available literature [4]. One may also argue that the overall
dichotomisation of the dosage cannot accurately represent the wide spectrum of the total length in
weeks, total number of hours, or the total number of contact hours per week. Indeed, our results confirm
the wide variability in weeks, contact hours, and intensity as previously reported [10]. Nevertheless, the
results of the meta-regression analysis using continuous variables of dosage were also not significant.
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In addition, large heterogeneity was found, but it cannot be explained from the dosage choices,
age, gender, low risk of bias, or type of control as presented in the published RCTs. This extensive
heterogeneity contributed to different results from fixed and random-effects models with respect to the
comparison between length and contact of treatment, and it can be better explained by the variation
in professional teams and the contents of the IMPT. Finally, we based our research on studies from a
Cochrane systematic review from 2014, and, despite the additional search on PubMed, we may have
missed some information.
This study does not suggest that IMPT is not beneficial for patients with CLBP. On the contrary,
our results found reliable but moderate effects on pain and disability following previous evidence [1–4].
In addition, even if IMPT dosage remains controversial, the lack of association between dosing and
outcome effects may mean that the rehabilitation professionals should reconsider adopting lower
dosages. We also assumed that an IMPT with duration of at least five weeks with non-daily contact
and low intensity would reduce pain and disability and the costs of such treatments, and increase the
rehab participation of patients suffering from chronic symptomatology, thereby avoiding exhaustive
and long treatments. In turn, active participation could lead to more beneficial results. Undoubtedly,
CLBP is a major cause of concern globally [7,26,27] and one of the leading causes of years lived with
disability [28]; therefore, optimal treatments are needed [29].
5. Conclusions
In this study, we showed that the IMPT dosing in general is not associated with better effects
on pain, disability, work status, quality of life, depression, and anxiety in patients with non-specific
CLBP. Some evidence suggests the efficacy of a long program with non-daily contact and low intensity
for only pain and disability per individual outcome level, but an overall optimal dosage was not
likely to be identified. This knowledge will contribute to a better evaluation from pain rehabilitation
professionals to obtain insight into dosage choices that may contribute to more efficacious treatments.
Further research on this topic examining also long-term outcomes is warranted.
Supplementary Materials: The following are available online at http://www.mdpi.com/2077-0383/8/6/871/s1.

Figure S1: Study flow diagram, Figure S2: Funnel plot for the pain outcome. Egger’s test for publication
bias was not significant (p = 0.141), Figure S3: Funnel plot for the disability outcome. Egger’s test for publication
bias was significant (p = 0.018), Figure S4: Funnel plot for the return to work outcome. Egger’s test for publication
bias was not significant (p = 0.141), Figure S5: Funnel plot for the quality of life outcome. Egger’s test for
publication bias was significant (p = 0.060), Figure S6: Funnel plot for the depression outcome. Egger’s test for
publication bias was significant (p = 0.081), Figure S7: Sensitivity analysis by length for the pain outcome, after
excluding the study of Moticone et al. (2013/2014), Figure S8: Sensitivity analysis by contact for the pain outcome,
after excluding the study of Moticone et al. (2013/2014), Figure S9: Sensitivity analysis by intensity for the pain
outcome, after excluding the study of Moticone et al. (2013/2014), Figure S10: Sensitivity analysis by length for the
disability outcome, after excluding the study of Moticone et al. (2013/2014), Figure S11: Sensitivity analysis by
contact for the disability outcome, after excluding the study of Moticone et al. (2013/2014), Figure S12: Sensitivity
analysis by intensity for the disability outcome, after excluding the study of Moticone et al. (2013/2014), Figure S13:
Forest plot for the pain outcome all studies included, Figure S14: Forest plot for the disability outcome all studies
included, Figure S15: Forest plot for the return to work outcome all studies included, Figure S16: Forest plot for the
quality of life outcome all studies included, Figure S17: Forest plot for the depression outcome all studies included,
Figure S18: Forest plot for the anxiety outcome all studies included, Figure S19: The relative odds ratios (RORs)
and 95% confidence intervals (CIs) for each outcome at short term of a short-length treatment vs. long-length
treatment. The RORs were calculated with a fixed-effect model. A ROR >1 favours long length; a ROR <1 favours
short length, Figure S20: The relative odds ratios (RORs) and 95% confidence intervals (CIs) for each outcome at
short term of a non-daily contact vs. daily contact. The RORs were calculated with a fixed-effect model. A ROR >1
favours daily contact; a ROR <1 favours non-daily contact, Figure S21: The relative odds ratios (RORs) and 95%
confidence intervals (CIs) for each outcome at short term of a low intensity vs. high intensity. The RORs were
calculated with a fixed-effect model. A ROR >1 favours high intensity (i.e., >30 h per week); a ROR <1 favours
low intensity (i.e., <30 h per week), Figure S22: The relative odds ratios (RORs) and 95% confidence intervals (CIs)
for each outcome at short term of a short-length treatment vs. long-length treatment, after excluding the study of
Moticone et al. (2013/2014). The RORs were calculated with a random-effects model. A ROR >1 favours long
length; a ROR <1 favours short length, Figure S23: The relative odds ratios (RORs) and 95% confidence intervals
(CIs) for each outcome at short term of a non-daily contact vs. daily contact, after excluding the study of Moticone
et al. (2013/2014). The RORs were calculated with a random-effects model. A ROR >1 favours daily contact; a
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J. Clin. Med. 2019, 8, 871
ROR <1 favours non-daily contact, Figure S24: The relative odds ratios (RORs) and 95% confidence intervals (CIs)
for each outcome at short term of a low intensity vs. high intensity, after excluding the study of Moticone et al.
(2013/2014). The RORs were calculated with a random-effects model. A ROR >1 favours high intensity (i.e., >30 h
per week); a ROR <1 favours low intensity (i.e., <30 h per week), Table S1: Risk of bias (RoB) according to the
Cochrane Back Review Group criteria, Table S2: Results of the meta-regression analyses of potential moderators of
the six examined outcomes, Table S3: Checklist summarizing compliance with PRISMA guidelines, Box S1: Search
details in PubMed, Box S2: References of included RCTs.
Author Contributions: E.D. and B.G. had the idea for the project, and E.D. primarily designed the study, which
was discussed and finally approved by all authors. E.D. and M.B. extracted the data and E.D. ran the analysis. All
authors wrote the first draft and commented on different versions of the paper. All authors approved the final
version of the paper. The corresponding author had final responsibility for the decision to submit for publication.
Conflicts of Interest: The authors declare no conflicts of interest.
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Journal of
Clinical Medicine
Review
The Evolving Case Supporting Individualised
Physiotherapy for Low Back Pain
Jon Ford 1,2, *, Andrew Hahne 1 , Luke Surkitt 2 , Alexander Chan 2 and Matthew Richards 2
1 School of Allied Health, La Trobe University, Kingsbury Drive, Bundoora 3086, Australia
2 Advance Healthcare, 157 Scoresby Road, Boronia 3155, Australia
* Correspondence: J.Ford@latrobe.edu.au
Received: 19 August 2019; Accepted: 22 August 2019; Published: 28 August 2019
Abstract: Low-back pain (LBP) is one of the most burdensome health problems in the world.
Guidelines recommend simple treatments such as advice that may result in suboptimal outcomes,
particularly when applied to people with complex biopsychosocial barriers to recovery. Individualised
physiotherapy has the potential of being more effective for people with LBP; however, there is limited
evidence supporting this approach. A series of studies supporting the mechanisms underpinning and
effectiveness of the Specific Treatment of Problems of the Spine (STOPS) approach to individualised
physiotherapy have been published. The clinical and research implications of these findings are
presented and discussed. Treatment based on the STOPS approach should also be considered as an
approach to individualised physiotherapy in people with LBP.
Keywords: low-back pain; physiotherapy; individualisation
1. Introduction
Low-back pain (LBP) is recognised as a common and costly problem in the Western world, with a
global prevalence of 0.5 billion, the highest ranking cause of years lived with disability contributing
57·6 million years [1], and an increase in prevalence and disease burden of nearly 20% over the last 10
years [2]. People with LBP have historically been described as having a favourable natural history [3];
however, systematic reviews of primary care studies show that 28%–79% of people with acute LBP
experience persistent or recurrent symptoms at 12 months [4,5]. Higher rates are supported by one
large general population study which is likely to be a more accurate measure of persistency/recurrence
than samples recruited from primary care settings [6].
Syntheses of clinical guidelines suggest international consensus in recommending initial exclusion
of red flags and radiculopathy, and subsequent management of LBP as a “non-specific” condition on
the basis that a nociceptive cause of symptoms cannot be identified [7–9]. Guideline-based treatment
(Table 1) aims to minimise potential harm of treatments such as surgery or medication and maximise
cost-effectiveness by utilising simple treatments such as advice [10,11]. However, the randomised
controlled trials (RCTs) upon which guideline recommendations are based typically show small effect
sizes of questionable clinical importance [8,9,12].
A potential reason for the limited effects demonstrated in RCTs on LBP is a false assumption that
non-specific LBP is a homogeneous group. It has been postulated that multiple subgroups exist within
the non-specific LBP population that are likely to respond differently to generic treatment [13]. In
such circumstances, a false assumption of sample homogeneity in RCTs may lead to a treatment being
inappropriately applied, resulting in either failure to respond or exacerbation of the condition. Based
on this understanding, identifying valid subgroups for the purposes of an RCT has been described
as a high research priority [14,15]. Meaningful subgroups enable treatment to be individualised to
the patient presentation, potentially increasing the size of the effect [16]. An example of the value of

J. Clin. Med. 2019, 8, 1334
individualised treatment is the management of inflammation in people with LBP. Guidelines suggest
that non-steroidal anti-inflammatory drugs (NSAIDs) have small and short-term positive effects for
LBP [8], yet these recommendations are based on RCTs selecting people with non-specific LBP. It is
unlikely that every patient in this population has LBP with inflammatory processes as a contributing
factor. It is, therefore, plausible that RCTs sampling populations with a greater likelihood of an
inflammatory component to their LBP would show larger effects.
Table 1. Overview of interventions endorsed for non-specific low-back pain in evidence-based clinical
practice guidelines (adapted from Foster et al. 2018) [9].
Acute LBP (<6 weeks) Persistent LBP (>12 weeks)

Advice
Advice Education
First line care
Education Exercise
CBT
NSAIDs
Selective norepinephrine reuptake inhibitors
NSAIDs Manual therapy
Superficial heat Acupuncture
Second line or adjunctive
Manual therapy Yoga
care
Massage Mindfulness
Acupuncture Interdisciplinary rehabilitation
Discectomy or laminectomy for disc
herniation with associated radiculopathy
Opioids
Limited use in selected Skeletal muscle relaxants Opioids
patients Exercise Epidural injection
CBT
Paracetamol
Paracetamol
Not recommended Systemic glucocorticoids
Systemic glucocorticoids
Epidural injection
Mindfulness
Interdisciplinary rehabilitation
Selective norepinephrine reuptake Superficial heat
Insufficient evidence
inhibitors Skeletal muscle relaxants
Antiseizure medication
Any surgery
CBT = cognitive behavioural therapy, NSAIDs = non-steroidal anti-inflammatory drugs.
The argument for the importance of individualised treatment is further strengthened by considering
the multi-dimensional nature of LBP. Clinical guidelines for LBP [9], the World Health Organisation’s
International Classification of Functioning, Disability and Health [17] and internationally accepted
standards on clinical reasoning [18] all emphasise multiple factors that are relevant for the management
of LBP including the pathoanatomical (e.g., nociceptive source of symptoms), psychosocial (e.g.,
fear avoidance), neurophysiological (e.g., central sensitisation and neuropathic pain) and genetic
dimensions. The complexity of LBP is also reflected in the wide range of subgrouping approaches
reported in systematic and narrative reviews [13,19–21]. Given the multidimensional and complex
nature of LBP, it is almost axiomatic that a “one size fits all” approach to treatment provision in RCTs is
likely to yield suboptimal results [13].
Based on the scale of the LBP problem, the limited data on treatment effectiveness, and the
potential value of individualised treatment, the aim of this paper was to overview the evidence on
individualised physiotherapy, including a contextualised presentation and discussion of a series of
studies on the Specific Treatment of Problems of the Spine (STOPS) approach.
2. The Evidence on Individualised Physiotherapy for Low-Back Pain

A search on the evidence supporting individualised physiotherapy for LBP was conducted on
PubMed using the Boolean term OR for individ*, subgroup*, classif* AND back pain AND “review” in
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J. Clin. Med. 2019, 8, 1334
the title. Reference lists of the retrieved papers, as well as recent clinical guidelines [7–9], were also
checked for relevant evidence. A total of 546 citations were identified from PubMed, with 12 being
deemed relevant for this overview.
Individualising treatment for LBP has been identified as a high research priority by a series of
international expert panels [14,15] and a methodological framework for future research suggested [19,22].
However, research investigating the large number of heterogenous approaches for individualising
treatment are of variable methodological quality [20,23–27]. Individualising physiotherapy based on
movement is recommended in a professional guideline [28] but is not supported by recent clinical
trials [29]. The STarT Back approach to individualising physiotherapy has been extensively researched in
different contexts [30–42], and is recommended in clinical guidelines based on cost effectiveness [8,9].
However, the STarT Back approach only confers small clinical effects on activity limitation, and no
long-term effects on pain compared to usual care [33].
Given the limited evidence supporting attempts to develop effective individualised physiotherapy
approaches for LBP, exploration of alternative methods has merit.
3. A Series of Studies Supporting Individualised Physiotherapy for Low-Back Pain

The STOPS trial was a randomised controlled trial (n = 300) published in 2016 that concluded
individualised physiotherapy was more effective than guideline-based advice for early persistent
LBP [43]. This trial was part of a series of studies that will be overviewed to inform a discussion on the
STOPS approach to individualised physiotherapy for LBP.
3.1. Prognosis in Identifying Potential Targets for Individualised Physiotherapy

Identification of prognostic factors can improve clinical decision making, understanding of disease
processes, definitions of risk groups, and prediction of clinical outcomes [44]. Prognostic factors can also
assist in identifying treatment targets to improve the effectiveness of individualised treatment [45,46].
Exploring and identifying gaps in the prognostic literature for LBP has been recommended as a research
priority [47].
Prognostic studies and systematic reviews on LBP commonly evaluate specific prognostic
factors [47,48] such as psychosocial distress [49–52], clinical features [53–56] and physical activity [57].
We are unaware of any high-quality studies evaluating a comprehensive range of biomedical (including
pathoanatomical), psychological and social prognostic factors using multivariate methods in a large
sample of people with LBP [46,58,59].
We, therefore, conducted a study that aimed to develop a multivariate prognostic model for
back pain, leg pain and activity limitation in patients with LBP based on a comprehensive range of
commonly used prognostic factors reflective of the biopsychosocial model of health [60]. Following
univariate analyses of a range of variables from 300 participants in the STOPS trial, 58 variables
progressed to multivariate analysis (Table A1). Five indicators of positive outcome (belonging to
either the reducible discogenic pain or disc herniation with associated radiculopathy subgroups, below
waist paraesthesia, walking as an easing factor and low transversus abdominis tone) and 10 indicators
of negative outcome (both parents born overseas, deep leg symptoms, higher sick leave duration
on the Örebro Musculoskeletal Pain Questionnaire [61], high multifidus tone, clinically determined
inflammation [62,63], higher back and leg pain severity, lower Oswestry Disability Index [64] lifting
capacity, lower capacity for light work (Örebro item) and higher Pain Drawing [65] scores based on
percentage body chart coverage) were identified (Table 2).
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J. Clin. Med. 2019, 8, 1334
Table 2. Back related healthcare utilization and costs per patient.
Resource Use: Units/Patient

Resource Cost/Patient (SD) in US$
(SD), % of Patients Utilizing
Between-Group Cost
IP Advice IP Advice
Difference (95% CI) *
Study physiotherapy 8.9 (2.1), 100% 1.8 (2.4), 99% 379.35 (87.10) 81.93 (18.46) 297.72 (282.85 to 312.01)
Medical consultations 1.7 (5.3), 32% 2.0 (4.2), 40% 86.95 (280.78) 110.55 (238.03) −23.61 (−85.61 to 38.40)
Medical intervention
Surgery (discectomy) 0.01 (0.08), 0.7% 0.02 (0.12), 1.5% 35.81 (434.18) 80.99 (650.40) −45.18 (−174.68 to 84.32)
Injections 0.1 (0.3), 3.4% 0.1 (0.5), 7.7 5.87 (36.32) 13.82 (56.10) −7.95 (−19.01 to 3.10)
Allied health consultations 3.3 (6.3), 38.8% 7.9 (12.3), 60.8% 152.38 (292.15) 324.47 (480.14) −172.09 (−264.94 to −79.25)
Medication 57.0% 54.6% 59.87 (140.54) 85.60 (207.93) −25.73 (−69.16 to 17.69)
782.82 (623.82 755.79 (592.84
Total Healthcare cost (95%CI) 27.03 (−200.29 to 254.35)
to 941.82) to 918.75)
$1889.16 $3884.67
10.8 (4.6 to 17.1) 20.5 (13.3 to $ −1995.51 (−3847.03 to
Work absence: Mean (95%CI), % (680.86 to (2497.22 to
days, 36% 27.6) days, 44% −143.98)
3097.46) 5272.12)
IP = individualised physiotherapy; SD = standard deviation; *, Between-group comparisons analysed via linear
mixed models, with positive values representing a higher cost in the individualised physiotherapy group relative to
the advice group, significant between-group differences in bold.
Researchers and clinical practice guidelines [66] have suggested that biomedical factors are
less relevant in the management of non-specific LBP and few studies have identified biomedical
or physical factors of prognostic value [67]. However biomedical factors are commonly used by
clinicians in decision making [68]. In our study, nine of the 15 prognostic factors related primarily
to pathoanatomical mechanisms. In addition, previously reported psychosocial predictors such
as depression, fear avoidance and recovery expectations were not prognostic when analysed in a
multi-variate model of a comprehensive range of prognostic factors. These results provide support
for the validity of the STOPS approach of individualised treatment based on a range of biomedical,
psychological and social factors.
3.2. Development of an Individualised Physiotherapy Treatment Program

Identifying subgroups of different types of LBP is one way of individualising physiotherapy,
and treatment targeting specific features or causal mechanisms underpinning the nature of the
subgroup has the potential of being more effective in RCTs [13,16]. However, developing a LBP
subgrouping system is challenging and the review literature shows that a wide array of approaches
exist [13,19–21,25–27,29,69–72]. Historically, subgrouping systems have been developed by experts
combining the best available evidence with their own clinical experience [73–77]. More recently,
a standardised approach to subgroup development used in the medical domain [78] has been
extrapolated to LBP [19,79] involving: initial evaluation of assessment methods of potential utility for
subgrouping, hypothesis setting studies using a range of methodologies, a priori hypothesis testing
studies and a series of further validation stages including analysis of impact of the subgrouping
system on routine care (Figure 1). A key component of the hypothesis generation, hypothesis testing
and subgroup validation studies is evaluation of treatment effect modifiers within a RCT. Treatment
effect modifier studies aim to assess whether the effect of a treatment (relative to a comparison
treatment) is different in people with certain characteristics (which are of potential use in defining
a subgroup), compared to those without [80]. However, to be adequately powered treatment effect
modifiers studies need to be around four times larger than studies investigating overall treatment
effect [81,82]. Given the complexity of LBP, a relatively large number of variables require exploration
for relevance to subgrouping, which further increases the necessary sample size in treatment effect
modifier studies [83]. These issues mean that treatment effect modifier RCTs, with the associated
high costs, are of questionable feasibility, particularly in certain research funding contexts such as
Australia [71,84,85].
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Figure 1. Conceptual phases of subgrouping research (adapted from Kent et al [19]).
A range of methodologies other than treatment effect modifiers can be used in the hypothesis
setting stage of subgroup development, although each approach has significant limitations. Studies
evaluating the diagnostic accuracy of different subgroup features/clinical measures are limited by the
absence of suitable reference standards [7]. Commonly used reference standards such as imaging,
discography and diagnostic blocks have all demonstrated significant false positives due, at least in
part, to the complexity of LBP including psychosocial and neurophysiological influences [86]. Despite
growing popularity [87] and defined methodological rigour, ‘data driven’ analyses for identifying and
developing subgroups also have significant limitations. Statistical processes can result in artificial
subgroups [88] of limited clinical use and/or meaningfulness [20,21,83] and a degree of judgement is
required in undertaking the analyses with the potential for bias [20,88–90].
Contemporary methodologies for the development and validation of subgrouping systems work
well in certain medical contexts to allow greater individualisation of treatment [78]. Yet, as described
above, extrapolation of these principles to the complex domain of LBP has limited feasibility and
methodological shortcomings. An alternative approach is the principle of “convergence of validity”
described as when “ . . . evidence supporting or refuting the (subgrouping) system (is) gathered from
different sources and from the use of different methods. In the best case scenario, these sources converge
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J. Clin. Med. 2019, 8, 1334
and indicate similar meanings of the underlying constructs being studied.” [91] (p. 312). Implicit in this
approach is an acceptance of the limitations of all research designs in relation to subgroup development.
As an alternative subgrouping strategy, convergence of validity is consistent with the original
definitions of evidence-based practice that emphasise the constructive interaction between the research
literature and clinical perspectives [92]. It also aligns with expert recommendations from the field of
epidemiology [93] and mirrors the approach taken in other complex medical domains such as the
classification of headache [94] and non-Hodgkin’s lymphoma [95].
In essence, a convergence of validity approach is the equivalent to the hypothesis setting phase
where a range of research methodologies are considered in developing a subgrouping system. In
applying a convergence of validity approach, it is accepted that the complete validation of such a
system, particularly through repeated treatment effect modifier studies, is not likely to be feasible. Yet
this limitation in achieving full validation should not prohibit the use of the subgrouping system in
other research designs, such as RCTs, provided the limitations of system validity are acknowledged.
Four papers [83,96–98] have been published in relation to the STOPS trial justifying and outlining
detailed individualised treatment protocols on the basis of convergence of validity supporting five
subgroups. This process has been further supported by two expert panels [99,100] and five systematic
reviews [20,101–104]. Four of the subgroups were primarily based on clinical features indicative of
a pathoanatomical diagnosis of the LBP and comprised: reducible discogenic pain, zygapophyseal
joint pain, non-reducible discogenic pain, and disc herniation with associated radiculopathy. A fifth
subgroup (multi-factorial persistent pain) captured people without a clear pathoanatomical classification
along with likely psychosocial contributors to their delayed recovery as measured on the Örebro
Musculoskeletal Pain Questionnaire [61].
Participants with reducible discogenic pain were prescribed a home program based on
mechanical loading strategies that led to improvement or centralisation of symptoms. This included
repeated/sustained movement exercises, a walking program, taping and postural advice [83].
Participants with zygapophysial joint dysfunction received targeted manual therapy comprising
unilateral mobilisation ± manipulation applied with a rigorous clinical reasoning approach [96].
All participants apart from those in the MFP group received motor-control training targeting
local muscles such as transversus abdominus leading into a pain contingent graded functional
exercise program [96]. This was the primary treatment for participants with disc herniation with
associated radiculopathy or non-reducible discogenic pain. Those with multifactorial persistent pain
received physiotherapy focusing on psychosocial and neurophysiological rather than pathoanatomical
mechanisms [98]. Progression of functional exercise in this subgroup was time-contingent, and
cognitive restructuring/behavioural strategies were used targeting key barriers identified on the Örebro
Musculoskeletal Pain Questionnaire.
Although subgroup membership determined the primary treatment approach, a range of other
treatment components were also provided depending on identification of other pathoanatomical,
psychosocial or neurophysiological barriers to recovery. All participants receiving individualised
physiotherapy engaged in an explanation/discussion regarding: the nature/source of their symptoms,
treatment options available outside of the RCT and timeframes for recovery. Participants also
worked with the trial physiotherapists on goal setting, cognitive restructuring of counterproductive
beliefs, behavioural strategies to support and reinforce the education program, as well as modifying
unproductive behaviours and discharge planning. A range of optional treatment components
were provided including: pain management strategies (pharmacological and non-pharmacological),
management of inflammation in participants with a clinically determined inflammatory component
to their pain, management of work issues, sleep strategies, relaxation and dealing with increases in
pain (flare-ups). In participants failing to improve with a pathoanatomical approach initially, the trial
physiotherapist determined whether transfer to the MFP treatment protocol was required. These
treatment strategies were all applied in a manner individualised to the participant’s presentation as
determined by the trial physiotherapist.
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3.3. Effectiveness of Individualised Physiotherapy

Based on the above-described research, the STOPS trial aimed to evaluate the effectiveness of
individualised physiotherapy compared to guideline-based advice. Advice regarding prognosis and
resuming normal activities is recommended in all clinical guidelines for people with LBP of over
6-weeks duration [8]. Prior to our clinical trials, there had been few published RCTs evaluating the
effectiveness of individualised physiotherapy compared to guideline-based advice.
Other recent subgrouping approaches based on risk stratification such as STarT Back [33] and
physical examination findings (i.e., movement patterns) do not address pathoanatomical factors despite
this approach being common in clinical practice and the convergence of evidence that it may be
important in clinical decision making for LBP [16,83,96–98].
Using the STOPS individualised physiotherapy protocol including manual therapy, directional
preference management, postural re-education, motor control training, and graded functional
exercise [83,96–98] we evaluated the effectiveness of individualised physiotherapy compared
to guideline-based advice for 300 participants with early persistent LBP (6-weeks to 6-months
duration) [43].
Results (Figure 2) showed that individualised physiotherapy was more effective than advice in
improving activity limitation (at 10, 26 and 52-weeks) as well as back pain and leg pain (at 5, 10 and
26-weeks). Between-group mean differences were statistically significant in 71% of the primary and
secondary outcomes measured in the trial. Participants receiving individualised physiotherapy took
5-8 weeks to achieve the same pain rating as those receiving advice at 12 months indicating a more
rapid rate of recovery. Satisfaction with individualised treatment was high, and 92.3% of individualised
physiotherapy participants completed the intervention. Based on contemporary definitions, these
results are clinically important [105,106].
Figure 2. Group mean scores (error bars indicate standard errors) for primary outcomes at baseline and
5-, 10-, 26- and 52-week follow-up in the STOPS Trial (adapted from Ford et al. [43], permission admitted).
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3.4. Cost-Effectiveness of Individualised Physiotherapy

Direct healthcare costs attributable to people with LBP in Western countries seeking healthcare is
estimated at billions of dollars annually [107,108] and is predicted to rise [109,110]. Treatments that
improve clinical outcomes such as pain and activity at a sustainable cost are urgently needed [111].
Guideline-based advice is a low-cost treatment that is commonly prescribed by medical
practitioners [112] and physiotherapists [113]. However, low cost does not necessarily correspond to
cost-effectiveness when treatment effects and all relevant costs (healthcare and other) are considered.
There is insufficient evidence regarding the cost-effectiveness of advice for LBP according to one
systematic review [111].
The STOPS trial showed that individualised physiotherapy was clinically more effective than
guideline-based advice [43]. Given the treatment cost of delivering individualised physiotherapy
(10 sessions) was higher than advice (2 sessions), consideration is required as to whether the larger
effects were worth the additional cost. We therefore investigated the cost-effectiveness of individualised
physiotherapy versus advice in people with LBP enrolled in the STOPS trial [114].
The results showed that total health care costs were similar for both groups despite individualised
physiotherapy being more expensive than guideline-based advice (Table 2). This was due to 61%
of participants receiving advice seeking further non-medical treatment outside the trial compared
to 39% of participants receiving individualised physiotherapy (Table 2). Health benefits favoured
individualised physiotherapy over advice (incremental Quality Adjusted Life Years = 0.06 (95%CI: 0.02
to 0.10)). Cost-effectiveness was established by the achievement of an Incremental Cost Effectiveness
ratio of $US 422 per quality adjusted life year gained [114]. In addition, lower work absence across
the 12-month follow-up resulted in income savings of $US 1995 (95%CI: 144 to 3847) per working
participant in the individualised physiotherapy group compared to the advice group (Table 2).
3.5. Who Benefits Most from Individualised Physiotherapy Versus Advice?

Treatment effect modifier studies are helpful for determining characteristics of patients who
respond best to a particular treatment relative to another in an RCT [19]. The STOPS treatment effect
modifier study investigated several patient characteristics identified a priori and listed on the trial
register [115] based on the hypothesis that participants with more severe, persistent or complex LBP
would derive the largest benefits from individualised physiotherapy relative to advice. This hypothesis
was supported by the results showing that participants with higher back pain intensity, higher Örebro
scores (indicative of higher risk of persistent pain) or longer duration of symptoms derived the
largest benefits from individualised physiotherapy relative to advice. These findings are of particular
importance because the presence of these characteristics has been associated with a worse prognosis
as well as higher treatment and societal costs [107,116,117]. Targeting individualised physiotherapy
towards these higher risk groups may, therefore, result in even stronger treatment effectiveness and
cost-effectiveness than those reported for the whole sample involved in the STOPS trial.
4. Discussion
Research into individualised physiotherapy is a high research priority that has, to date, yielded
disappointing results in RCTs. The series of studies described in this paper support the development
and validity of the STOPS subgrouping approach. In addition, three studies on the effectiveness,
cost-effectiveness and treatment effect modifiers provide further support for the individualised
treatment of LBP using the STOPS approach. We are unaware of any similar body of research on the
utility of individualised physiotherapy based on a comprehensive biopsychosocial-based treatment
model. There are a range of possible factors that may have contributed to the above-described results.
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4.1. The Definition of Clinical Importance

Most RCTs on LBP demonstrating statistically significant results show small effects of questionable
clinical importance [8,9]. However, the traditional definition of clinical importance based on the
minimal clinically important difference (MCID) has been questioned given it was developed for
use on individuals rather than group data and may not be appropriate for people with lower
severity symptoms [105,118]. Authoritative contemporary guidelines recommend determining clinical
importance using multiple methods of analysis including consistency of results across multiple primary
and secondary outcome measures, risks/benefits of the treatments, consideration of the population
being sampled, and the proportion of individual patients who demonstrate change in outcome
measures in excess of the MCID in addition to between-group differences in mean scores [106,119,120].
The STOPS trial did not demonstrate clinically important between-group mean differences based
on the MCID. However, in accordance with our a priori statistical plan [121], a primary outcome
responder analysis was conducted. This analysis showed that participants receiving individualised
physiotherapy had 1.8 and 1.6 times the chance of improving by at least 50% from baseline on back
and leg pain, respectively, at the 10-week follow-up compared with those receiving advice alone.
By 52 weeks, those having individualised physiotherapy also had 1.5 times the chance of improving by
50% from baseline on the Oswestry Disability Questionnaire compared with those receiving advice. All
secondary outcomes favoured individualised physiotherapy, with the exception of work interference,
but the cost-effectiveness study showed significantly lower work absence (and associated lost income)
in the individualised physiotherapy group. In the secondary-outcomes responder analysis, participants
receiving individualised physiotherapy had 1.3–4.1 times the chance of achieving a clinically important
change compared with those receiving advice. Participant satisfaction was significantly greater and
non-medical co-interventions significantly lower in the individualised physiotherapy group. All
between-group comparisons should be interpreted in the context of large within-group improvements
on all primary outcomes for both treatment groups [33]. Given the population sampled were ≥6-weeks
post-injury where spontaneous recovery is limited [4,5], it is likely that both treatments were helpful,
with individualised physiotherapy conferring additional benefits over and above advice. There were
no serious adverse events in either group and with detailed published clinical protocols available, the
STOPS approach to LBP is potentially accessible worldwide without extensive training common to
other individualised physiotherapy approaches [33,122].
The clinical importance of the between-group differences as a measure of significance in the
STOPS trial is further strengthened by the cost-effectiveness analysis. Results showed an incremental
cost-effectiveness ratio (ICER) of US$422 per quality-adjusted life year (QALY), which compares
favourably to other relevant RCTs in the field. Cognitive behavioural therapy is recommended in all
clinical guidelines for LBP [8,9], but has an ICER of US$2773 per QALY gained for group cognitive
behavioural therapy along with advice versus advice alone [123]. In another relevant RCT [124] five
sessions of physiotherapy were not cost-effective compared with one session of advice as there were
no significant differences in health outcomes. These data further support the clinical importance of the
STOPS trial results by way of cost-effectiveness compared to guideline-based advice.
Another potential indicator of clinical importance from RCTs is the proportion of participants who
complete the intervention. High drop-out rates in clinical trials may indicate that the intervention is not
acceptable to participants on the basis of ineffectiveness, patient preferences, the required commitment
to comply with treatment, or side-effects. Drop-out rates exceeding 15% have been reported for
multiple LBP trials of graded activity [125], anticonvulsants [126], and in one trial of individualised
physiotherapy [122]. The individualised physiotherapy group in the STOPS trial had a 7.7% drop-out
rate, suggesting that the treatment was acceptable for most participants and giving further support to
the clinical importance of the STOPS trial results.
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4.2. Comparison Group Selection and Advice

When designing and interpreting RCTs, it is important for the researcher and consumer to carefully
consider the comparison group. Common trial designs in LBP use no treatment, placebo treatment,
advice, usual medical care or various types of physiotherapy interventions. There is no right or wrong
approach to designing a comparison group in an RCT; it simply informs the hypothesis being tested.
For example, a RCT comparing manual therapy to placebo manual therapy is designed to test the
specific effect of manual therapy independent of any non-specific effects such as patient expectations,
learning/conditioning effects and neurophysiological effects [127].
It is worth reflecting on the use of guideline-based advice in designing a RCT. Advice to
stay active and reassurance regarding prognosis is recommended as first-line treatment in all
clinical guidelines for acute and persistent LBP as described in Table 1 [9]. The evidence directly
supporting the effectiveness and cost-effectiveness of guideline-based advice is sparse [111,128–130].
Nevertheless, it has been asserted that this treatment is just as effective as more costly and complex
treatments [10,11]. Although not commonly used as the sole treatment approach by practitioners in
the field [131], guideline-based advice is being advocated strongly as first line treatment ahead of
other physiotherapeutic treatments such as manual therapy as well as medical treatments such as
NSAIDs [8,9,131,132]. Given the low-quality evidence supporting guideline-based advice, it is possible
that this approach is counterproductive, particularly if second-line treatments are more effective
without being prohibitively more expensive. On this basis, guideline-based advice is an important
comparison group in a RCT evaluating the effectiveness of commonly used second-line treatments
(Table 1).
4.3. Use of a Pathoanatomical Approach

A major difference between the STOPS trial and the majority of the LBP research was the
incorporation of pathoanatomical factors into the subgrouping approach and pathoanatomical-based
decision making in the clinical protocol. Definitive criteria for pathoanatomical-based diagnosis and/or
clinical decision making in LBP are not available [8]. It has been suggested that further research into
and clinicians hypothesising about pathoanatomical barriers to recovery is likely to be at best, futile
and, at worst, counterproductive to patient outcomes [66,133,134]. However, there is sparse evidence
supporting this contention [16] and a pathoanatomical approach is common in clinical practice [68].
In addition, although there are likely to be benefits from addressing exercise/activity, lifestyle and
psychosocial factors, the prognostic and treatment effects are small [134]. On this basis, it does not seem
sensible to abandon clinical and research-based hypothesising on the role of pathoanatomy unless
compelling evidence to do so is provided. Guideline-based advice is not informed by pathoanatomy
and the mechanisms of effect are likely to be non-specific. As such, it is possible that a reason for
the significant between-group differences in the STOPS trial was that assessment and treatment
incorporated hypothesised pathoanatomical diagnoses and related clinical decision making. This
premise was supported by the prevalence of pathoanatomical factors in the STOPS prognostic study
and the convergence of results from a range of other research designs [83,96–98]
One example of this approach is the STOPS protocol, where treatment was individualised based
on the hypothesised presence or absence of an inflammatory component to the LBP. The lumbar
intervertebral disc is a biologically plausible contributor to LBP [135]. The mechanisms underpinning
the symptoms of disc related pain and activity limitation are unclear, however substantial evidence
exists supporting the role of inflammation in disc degeneration and disc herniation with associated
radiculopathy (DHR) [136,137]. Studies investigating the composition and structure of lumbar discs
have shown fibrosis, vascular invasion, inflammatory granulation tissue formation and extensive
innervation along fissures in the posterior annulus fibrosis in painful degenerative discs and around
symptomatic nerve roots. Such changes are not observed in non-painful degenerative or herniated
discs [138,139].
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Further evidence on the presence of and potential importance of inflammatory processes in

degenerative discs and DHR [140] can be seen in disc tissue histologically [141–145], in the disc tissue
using other inflammatory markers [146–151] and as measured by serum biomarkers in people with
LBP [152]. A recent study showed that high serum tumour necrosis factor in acute LBP predicted poor
recovery of pain and activity limitation at 6-months, providing further evidence of the relevance of
inflammation [153].
Significant evidence suggests that inflammatory processes are a potential treatment target in
clinical trials [136,137,154–156], particularly in people who may have discogenic pain [141–145].
Clinical features of inflammatory back pain such as spondyloarthropathy have been validated using
practitioner surveys, expert panels and diagnostic accuracy studies [63,157–160]. These features include
age <40 years, insidious onset, improvement with exercise, no improvement with rest and pain at
night with improvement upon getting up from bed [161]. These results are similar to studies on the
clinical features of disc related LBP and associated inflammation [144,145,147].
Although systematic reviews and guidelines suggest that NSAIDs are only a second-line treatment
option for the management of LBP (Table 1), the literature above suggests that management of
inflammatory processes might be more effective if targeted to individuals with clinical symptoms
indicative of inflammation, particularly with a combination of pharmacological and other relevant
management strategies. The clinical features suggestive of the presence of inflammation informed
clinical decision making in the STOPS trial regarding when to implement anti-inflammatory treatment
such as medication, taping, postural management and gentle walking. The identification of an
inflammatory component was also important where inflammation may have hindered the effectiveness
of mechanically based treatment approaches such as exercise, manual therapy or directional preference
management [162,163]. The STOPS trial was unique in identifying clinically determined inflammation
as a reason for exercising caution with mechanical treatment and simultaneously, treating inflammatory
problems using anti-inflammatory treatment. The guideline-based advice comparison treatment gave
no consideration to the role of inflammation. Therefore, clinical decision making based on the possible
presence/absence of inflammation may have been a factor contributing to the significant between-group
differences. This premise is further supported by the significance of clinically determined inflammation
identified in the STOPS prognosis study.
4.4. Treatment Fidelity in Randomised Controlled Trials

Methods to maximise treatment fidelity in RCTs for physiotherapy interventions are highly
variable and often poorly reported [164–169]. The STOPS trial employed a range of evidence-based
methods [170] to enhance treatment fidelity including: specification regarding the treatment program
design (140 page clinical manual with full detail on all aspects of individualised treatment); 16 hours of
standardised practitioner training; review of practitioner treatment and practitioner feedback during
the RCT (by way of study researchers reviewing the clinical notes followed by verbal feedback and
group-based monthly case reviews); and evaluation of the participant’s perspective/understanding
of the treatment provided (qualitative exit interviews). Participants also completed exercise diaries
that were checked by the physiotherapist at each visit. Similar methods were put in place with the
advice treatment program. Given the relative complexity of the individualised physiotherapy, it is
plausible that the treatment fidelity program would have had greater impact on patient outcomes in
the individualised physiotherapy group. This could, therefore, have been an additional factor for the
significant between-group differences observed in the STOPS trial.
4.5. The Importance of Motor Control

Motor control retraining focusing on posture, movement and muscle activation was a significant
component of individualised physiotherapy for all participants apart from those in the multifactorial
persistent pain (MFP) subgroup. The relevance and effectiveness of this approach is contentious [171]
and there are significant inconsistencies in systematic review results [172–174]. Nevertheless, as
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the advice group did not receive motor control training this treatment component could have been
responsible in part for the significant between-group effects. This premise is supported by the
significance of suboptimal motor control identified in the STOPS prognosis study as well as the
biological plausibility and potential pathoanatomical relevance of optimising motor control in people
with LBP [175–178].
5. Clinical Implications
The clinical implications of the research presented in this paper are potentially substantial but need
to be contextualised within an evidence-based framework. In order to make strong recommendations
to practitioners, the findings need to be replicated in independent samples and/or systematic reviews
updated to incorporate the relevant data into meta-analyses. However, the significance and consistency
of the results are sufficient to challenge some of the common perceptions around evidence-based
practice for LBP.
Guidelines routinely state that the vast majority of LBP patients should be considered as a
non-specific condition where consideration of pathoanatomy is not possible or necessary [8,9]. Some
guidelines go so far as to state that clinical decision making based on pathoanatomy may be harmful [66]
despite sparse data to support this assertion. The results presented in this paper support the notion
that hypothesising on and clinical decision making with regard to pathoanatomical considerations
cannot be discounted and may lead to superior outcomes compared to a less targeted approach.
There is sparse data supporting the effectiveness of simple guideline-based advice. It is of
interest that the RCT with the largest effect sizes in favour of advice incorporated a pathoanatomical
explanation [179]. Despite this, advice in the absence of a pathoanatomical explanation is being
recommended as first-line treatment for LBP of any duration [8,9]. The series of studies described in
this paper suggest that further consideration and evaluation of guideline-based advice as a first-line
treatment is required.
The generalisability of the STOPS trial results should be superior to most recent RCTs on
individualised physiotherapy, where only a few experienced practitioners were used [122] and/or
detailed clinical protocols were not published [33,122]. The treatment used in the STOPS trial
was provided by physiotherapists with a range of experience, none of whom had a post-graduate
qualification. It encompassed the most commonly used methods by physiotherapists [113,180,181]
however the published treatment protocols have the potential to improve the quality of existing
standards in clinical practice due to the detailed explanations and clinical decision making
processes provided.
On the basis of the STOPS trial, practitioners can provide their patients with an average timeframe
for expected treatment outcomes when receiving individualised physiotherapy. Patients are likely
to experience rapid reductions in back/leg pain in the first 10 weeks of treatment, but optimal
improvements in activity limitation are likely to take longer. Patients will also be reassured regarding
the cost-effectiveness of the treatment, particularly with regards to minimising time off work.
6. Future Research
The results of this series of studies should be highly impactful on future research. Much of the
research in LBP develop study designs, eligibility criteria, prognostic factors or treatment protocols
that are relatively simplistic in nature. Whilst this approach renders research projects more feasible
and potentially more methodologically rigorous, it does not reflect the real-world complexity of LBP
and the associated treatment options that are likely to be most effective.
A pathoanatomical approach should be considered when planning future clinical research within
the context of a truly biopsychosocial model for LBP.
More research is required on the relative importance of different components of individualised
physiotherapy. Individualised physiotherapy also needs to be compared to other comparison groups
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and on different populations, particularly persistent LBP where more entrenched psychosocial and
neurophysiological barriers to recovery are likely to be relevant.
Researchers should be encouraged by the clinical importance of the results in the STOPS trial and
be emboldened to develop ambitious research hypotheses based on an in-depth understanding of both
clinical and research perspectives.
Greater rigour should be applied to the development of clinical guidelines to ensure that
low-quality evidence such as the sparse data and questionable cost-effectiveness supporting simple
advice is acknowledged.
Researchers should follow the lead of the STOPS trial in providing detailed clinical protocols
that are feely available in full-text. Such an approach would greatly accelerate the dissemination of
evidence-based information to practitioners in the field and substantially improve external validity.
7. Conclusions
LBP is the most burdensome health problem in the world. Prior to the publication of the studies in
this body of research, there was limited evidence for the effectiveness of individualised physiotherapy
and a focus in clinical guidelines on advice as first-line treatment for LBP. Our series of studies
challenge the role of advice alone in early persistent pain and suggests that the concept of non-specific
LBP needs to be reconsidered. Furthermore, there are now detailed clinical protocols and quality
evidence to support the STOPS approach to individualised physiotherapy in clinical practice and
future research studies.
Author Contributions: Conceptualization, J.F. and A.H.; methodology, J.F., A.H., L.S., A.C. and M.R.; formal
analysis, A.H. and J.F.; data curation, J.F., A.H., L.S., A.C. and M.R.; writing—original draft preparation, J.F. and
A.H.; writing—review and editing, J.F., A.H., L.S., A.C. and M.R.; supervision, J.F.; project administration, J.F.,
A.H., L.S., A.C. and M.R.; funding acquisition, J.F.
Funding: Elements of the original research summarized in this review were supported by LifeCare Health, who
provided facilities, personnel and resources to allow treatment of participants free of charge in the STOPS Trial.
Acknowledgments: We wish to acknowledge the physiotherapists who treated participants in the STOPS Trial
free of charge.
Conflicts of Interest: The authors declare no conflict of interest LifeCare Health had no role in the design of the
study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, or in the decision to
publish the results.
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Appendix A
Table A1. Prognostic factors for Oswestry, back pain and leg pain obtained from the multivariate model.
Oswestry (0–100) Back Pain (0–10) Leg Pain (0–10)

Prognostic factor N B Coefficient (95% CI) p-value N B Coefficient (95% CI) p-value N B Coefficient (95% CI) p-value
Intercept −0.2 (−14.4 to 13.9) 0.975 0.0 (−1.962 to 2.019) 0.977 −2.0 (−4.3 to 0.4) 0.095
J. Clin. Med. 2019, 8, 1334
Subgroup
54 −1.3 (−5.0 to 2.3) 0.473 + 54 −0.6 (−1.2 to −0.1) 0.029 + 54 −0.3 (−0.9 to 0.3) 0.312 +
Disc herniation/radiculopathy *
Reducible discogenic pain * 78 −3.2 (−5.9 to −0.6) 0.017 + 78 −0.9 (−1.3 to −0.4) <0.001 + 70 −0.7 (−1.2 to −0.2) 0.005 +
Manual therapy group * 64 −2.6 (−5.5 to 0.3) 0.082 + 64 −0.5 (−1.0 to 0.0) 0.050 + 49 −0.2 (−0.7 to 0.4) 0.560 +
Multifactorial persistent pain * 8 −1.3 (−7.8 to 5.1) 0.683 + 8 0.2 (−0.5 to 0.8) 0.647 7 −0.2 (−1.4 to 0.9) 0.725 +
Parents born overseas
165 3.4 (1.1 to 5.7) 0.004 165 0.6 (0.2 to 0.9) 0.003 141 0.5 (0.1 to 0.9) 0.026
Both born overseas #
One born overseas # 21 0.7 (−3.7 to 5.1) 0.761 21 0.2 (−0.4 to 0.8) 0.570 18 0.1 (−0.5 to 0.8) 0.723
Paresthesia below waist 134 −3.3 (−6.0 to −0.6) 0.016 + 134 −0.1 (−0.5 to 0.3) 0.607 + 125 −0.2 (−0.6 to 0.3) 0.498 +
Deep leg symptoms 145 2.5 (0.0 to 4.9) 0.053 145 0.2 (−0.2 to 0.6) 0.286 145 0.6 (0.2 to 1.0) 0.002
Walking eases symptoms 160 −2.0 (−4.2 to 0.2) 0.073 + 160 −0.5 (−0.9 to −0.2) 0.005 + 138 −0.2 (−0.6 to 0.2) 0.273 +
Lateral flexion limited by pain 116 1.0 (−1.3 to 3.4) 0.382 116 0.1 (−0.3 to 0.5) 0.536 106 0.4 (0.0 to 0.8) 0.055
Transversus abdominis low tone 109 −3.0 (−5.3 to −0.7) 0.012 + 109 −0.8 (−1.1 to −0.4) <0.001 + 91 −0.4 (−0.9 to 0.0) 0.051
Multifidus high tone 60 2.0 (−1.2 to 5.1) 0.215 60 0.0 (−0.4 to 0.5) 0.918 47 0.7 (0.1 to 1.4) 0.019
296
Clinical inflammation 182 1.1 (−1.1 to 3.3) 0.342 182 0.4 (0.1 to 0.8) 0.020 165 −0.2 (−0.6 to −0.2) 0.311 +
Back pain severity 300 0.2 (−0.5 to 0.8) 0.556 300 0.3 (0.2 to 0.4) <0.001 261 0.1 (0.0 to 0.2) 0.245
Leg pain severity 300 0.1 (−0.5 to 0.6) 0.764 300 0.0 (−0.1 to 0.1) 0.896 261 0.3 (0.2 to 0.4) <0.001
Örebro sick leave duration (0–10) 300 1.1 (0.4 to 1.7) 0.002 300 0.1 (0.0 to 0.2) 0.112 261 0.1 (0.0 to 0.2) 0.219
*, relative to “non-reducible discogenic pain”’ #, relative to “both parents born in Australia”; +, Positive prognostic indicator. Results are independent of time point, significant p-values
in bold. Negative B-coefficients represent lower outcome scores and therefore a better outcome at follow-up in participants with the listed prognostic factor. Predicted outcome for a
given patient can be calculated by applying the patient’s score on each baseline factor to the B-coefficients, and adding the scores from each item together (including the intercept).
J. Clin. Med. 2019, 8, 1334
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Journal of
Clinical Medicine
Review
Are Mindful Exercises Safe and Beneficial for Treating
Chronic Lower Back Pain? A Systematic Review and
Meta-Analysis of Randomized Controlled Trials
Liye Zou 1,† , Yanjie Zhang 2,† , Lin Yang 3,4 , Paul D. Loprinzi 5 , Albert S. Yeung 6 , Jian Kong 6 ,
Kevin W Chen 1 , Wook Song 2,7 , Tao Xiao 8, * and Hong Li 9,10, *
1 Lifestyle (Mind-Body Movement) Research Center, College of Sports Science, Shenzhen University,
Shenzhen 518060, China; liyezou123@gmail.com (L.Z.); Qigong4us@hotmail.com (K.W.C.)
2 Health and Exercise Science Laboratory, Institute of Sports Science, Seoul National University, Seoul 08826,
Korea; elite_zhangyj@163.com (Y.Z.); songw3@snu.ac.kr (W.S.)
3 Cancer Epidemiology and Prevention Research, Alberta Health Services, Calgary, AB T2S 3C3, Canada;
lin.yang@ahs.ca
4 Departments of Oncology and Community Health Sciences, Cumming School of Medicine,
University of Calgary, Calgary, AB T2N 4Z6, Canada
5 Department of Health, Exercise Science and Recreation Management School of Applied Sciences,
The University of Mississippi, Oxford, MS 36877, USA; pdloprin@olemiss.edu
6 Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114,
USA; ayeung@mgh.harvard.edu (A.S.Y.); JKONG2@mgh.harvard.edu (J.K.)
7 Institute on Aging, Seoul National University, Seoul 08826, Korea
8 College of Mathematics and Statistics, Shenzhen University, Shenzhen 518060, China
9 Shenzhen Key Laboratory of Affective and Social Cognitive Science, College of Psychology and Sociology,
Shenzhen University, Shenzhen 518060, China
10 Shenzhen Institute of Neuroscience, Shenzhen 518057, China
* Correspondence: taoxiao@szu.edu.cn (T.X.); lihongszu@szu.edu.cn (H.L.)
† These authors contributed equally to this work.
Received: 28 March 2019; Accepted: 6 May 2019; Published: 8 May 2019
Abstract: Background: Chronic low back pain (CLBP) is a common health issue worldwide. Tai Chi,
Qigong, and Yoga, as the most widely practiced mindful exercises, have promising effects for
CLBP-specific symptoms. Objective: We therefore conducted a comprehensive review investigating
the effects of mindful exercises versus active and/or non-active controls while evaluating the safety and
pain-related effects of mindful exercises in adults with CLBP. Methods: We searched five databases
(MEDLINE, EMBASE, SCOPUS, Web of Science, and Cochrane Library) from inception to February
2019. Two investigators independently selected 17 eligible randomized controlled trials (RCT)
against inclusion and exclusion criteria, followed by data extraction and study quality assessment.
Standardized mean difference (SMD) was used to determine the magnitude of mindful exercises
versus controls on pain- and disease-specific outcome measures. Results: As compared to control
groups, we observed significantly favorable effects of mindful exercises on reducing pain intensity
(SMD = −0.37, 95% CI −0.5 to −0.23, p < 0.001, I2 = 45.9 %) and disability (SMD = −0.39, 95% CI
−0.49 to −0.28, p < 0.001, I2 = 0 %). When compared with active control alone, mindful exercises
showed significantly reduced pain intensity (SMD = −0.40, p < 0.001). Furthermore, of the three
mindful exercises, Tai Chi has a significantly superior effect on pain management (SMD= −0.75,
95% CI −1.05 to −0.46, p < 0.001), whereas Yoga-related adverse events were reported in five studies.
Conclusion: Findings of our systematic review suggest that mindful exercises (Tai Chi and Qigong)
may be beneficial for CLBP symptomatic management. In particular, Tai Chi appears to have a
superior effect in reducing pain intensity irrespective of non-control comparison or active control
comparison (conventional exercises, core training, and physical therapy programs). Importantly,
training in these mindful exercises should be implemented with certified instructors to ensure quality
of movement and injury prevention.

J. Clin. Med. 2019, 8, 628
Keywords: Tai Chi; Yoga; Qigong; mind-body therapy; exercise; mind-body medicine; low back pain
1. Introduction
Low back pain is a common health issue worldwide, but notably, prevention and treatment of
chronic low back pain (CLBP) is a major public health concern [1,2]. It has been widely recognized
as the leading cause of disability, affecting work performance and general psychosomatic health and
is associated with substantial economic and societal burden [2]. The estimated lifetime prevalence
of CLBP is 12% to 33% in industrialized countries (period prevalence: 22% to 65% per year) [3].
The prevalence rate of CLBP is higher in adults than children and adolescents [4], particularly
among the working population [5]. CLBP is widely treated with medications (e.g., nonsteroidal
anti-inflammatory drug, analgesic, and muscle relaxant) to relieve pain, decrease inflammation,
and reduce muscle tension [6]. However, these treatments may increase the likelihood of falls
and drug-related side effects (e.g., mood disturbance, nausea, seizure, and/or tachycardia) among
patients [6,7]. Furthermore, the long-term use of medications remains financially unaffordable in
economically disadvantaged areas [7]. Other non-pharmacological treatments, such as physical
therapy [8,9], spinal manipulation [10], and physical activity or exercise [11–13], have shown promising
effects on improving CLBP-specific symptoms.
Tai Chi, Qigong (e.g., Baduanjin, Yijingjin, and Wuqinxi), and Yoga, also known as mindful
exercises, are light-to-moderate intensity physical activities and have recently been popularized in both
the fitness industry and clinical setting for disease prevention and symptomatic management [14–17].
Mindful exercises are typically performed at a slow pace, simultaneously integrated with mental focus
on muscle and movement sense, rhythmic abdominal diaphragmatic breathing, and meditation [18–21].
These modalities may complement or act as an alternative practice to conventional rehabilitation
programs [22–24]. Mindful exercises are beneficial for symptomatic management in a variety of
diseases, such as multiple sclerosis [25,26], autism spectrum disorder [27], balance disorder [28,29],
ankylosing spondylitis [30], mental illness [31,32], cerebrovascular disease [33], fibromyalgia [34],
and knee osteoarthritis [35].
Recently, research has investigated the effects of mindful exercises in adults with CLBP. With the
increasing number of experimental studies on this topic, two reviews were subsequently performed and
published in 2013 [36,37]. Notably, these two systematic reviews only included eight to 10 randomized
controlled trials (RCT) and focused on Yoga alone. Secondly, meta-analysis was only possible for
the Yoga interventions versus non-active controls due to the small number of trials, lacking a direct
comparison to active control conditions like conventional exercises or guideline-endorsed treatments.
Thirdly, previous reviews simply evaluated the effectiveness of Yoga, but the safety of the broader
mindful exercises in adults with CLBP still remains unknown. To fill these knowledge gaps, we
therefore conducted an updated systematic review that includes all three most popular mindful
exercises versus active and/or non-active controls while evaluating the safety and efficacy of mindful
exercises in adults with CLBP.
2. Methods
2.1. Search Strategy

Two investigators independently searched five databases (MEDLINE, EMBASE, SCOPUS, Web of
Science, and Cochrane library) from the inception to February 2019. We used two groups of keywords:
(1) “Tai Chi” OR “Tai Chi Chuan” OR “Taiji” OR “Qigong” Or "Chi Kung“ OR ”Qi Gong“ OR
“Baduanjin” OR “Yijinjing” OR “Wuqinxi” OR “Yoga” OR “mind-body”, OR “mindful exercise”;
(2) “low back pain” OR “lower back pain” OR “back pain” OR “low back ache”. Hand-searching was
performed to identify relevant publications from the reference lists of eligible original articles and
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J. Clin. Med. 2019, 8, 628
reviews. In addition to two separate investigators independently searching the five above-mentioned
databases, these investigators also independently screened the titles and abstracts of the potentially
eligible articles (described below). Full details on the search strategy and retrieval process are shown
in Figure 1.
Figure 1. Flow chart of study searching.

In the present review, studies were only considered eligible if they: (1) were RCTs; (2) recruited
adults diagnosed with CLBP (low back pain lasting or recurring for longer than 3 months [38]; (3) used
at least one type of mindful exercise (e.g., Tai Chi, Qigong, and Yoga) or their combination as an
intervention program; (4) included a control group using any form (e.g., aerobic exercise, self-care
book, waitlist, or no treatment) other than mindful exercise; (5) reported at least one health outcome
associated with disease-specific symptoms like pain, functional ability, or depression. Exclusion criteria
were: (1) specific causes (e.g., spinal canal stenosis or herniated disc); (2) mindful exercise integrated
with other treatments, like core training; (3) unobtainable data for calculating effect size (ES); (4) other
types of publications, such as a case-study, observational study, or review articles.
2.3. Data Extraction and Quality Assessment

Detailed information of each included study were independently extracted by the two investigators
and a third reviewer was consulted to reach consensus by discussion. Extracted information included
the first author and year of publication, characteristics of participants (sample size and mean age),
intervention protocol (mindful exercise, control type, and intervention duration), outcome measure
(pain, disability, and/or depression), and reporting of an adverse event. In addition to descriptive
information, the same investigators extracted the quantitative data for ES calculation.
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J. Clin. Med. 2019, 8, 628
Two investigators independently assessed methodological quality using the Physiotherapy

Evidence Database (PEDro) scale. This scale consists of 11 items, including eligibility criteria, random
allocation, allocation concealment, baseline equivalence, blinded assessor(s), blinded participants,
blinded instructor, retention rate of ≥85%, intention-to-treat analysis (ITT), between group statistical
comparisons, and point estimates of at least one set of outcome measures. One point is awarded for
meeting each evaluation requirement. Since this review included all adults diagnosed with CLBP,
the first eligibility criteria was not considered. Thus, each study could reach a maximum of 10 points:
excellent (9–10 points), good (6–8 points), fair (4–5 points) and poor (less than 4 points) quality [39].

The Comprehensive Meta-Analysis Software version 2.2 was employed to meta-analyze the
extracted data. For each outcome, we used mean and standard deviations (SD) at baseline and
post-intervention, along with the number of participants per group. If one study included two control
groups, we halved the number of participants in the mindful exercise group with the two control
groups, while mean and SD remained unchanged. We used random-effects model to calculate the
pooled ES (standardized mean difference, SMD) to determine the magnitude of effect for mindful
exercise intervention on two outcomes (pain and disability). Notably, we did not evaluate depression
as an outcome variable, due to fewer than four studies evaluating this outcome [40]. Three levels of
ES were adopted: small (0.2–0.49), moderate (0.50–0.79), and large (≥0.8) [40]. I2 test was used to
determine heterogeneity across included studies: I2 < 25% (low), I2 < 50% (moderate), and I2 > 75%
(high), respectively [40]. Furthermore, we performed sub-group analyses for categorical variables
and meta-regression for continuous variables. The categorical variables included: (1) types of control
condition (mindful exercise versus active control or non-active control), mindful exercise (Tai Chi, Yoga,
and Qigong), and instrument; (2) use of allocation concealment. The continuous variables included
mean age and total time spent over the entire intervention course (minutes). Finally, publication bias
for each outcome was evaluated using the Egger’s test and the visually-produced Funnel plot [40].
Subsequently, we removed studies that caused asymmetry.
3. Results
3.1. Search Results

Figure 1 describes the detailed search process of our meta-analysis. A total of 2049 potential studies
were searched and 42 full-text publications were screened for further evaluation. After eliminating
the irrelevant studies (n = 25), seventeen studies [41–57] were identified for data extraction and
quality assessment.
3.2. Characteristics of Included Studies

Table 1 depicts the characteristics of the included studies, such as the sample size, age, intervention
and control group details, and outcome measures. Seventeen studies [41–57] published in peer-review
journals included a total of 2022 participants with CLBP. The mean age of participants ranged from 34
to 74 years. The sample size ranged from 20 to 320 per study. Intervention duration for the mindful
exercise(s) lasted 1 to 24 weeks, with sessions occurring one to seven times per week (40 to 90 min
per sessions). Control conditions varied greatly across the evaluated studies, including utilizing a
self-care book, stretching exercise, and waitlist. Adverse events were reported in five Yoga intervention
studies, including herniated discs (3.3% and 1.1%, respectively) [48,54,55], increased pain (2.6% and
14.1%, respectively) [53,54], and mild self-limited joint and back pain (7.1%) [56]. One study did not
report an adverse event [57], while no adverse events were reported in the other mindful exercise
intervention studies.
310
Table 1. Characteristics of randomized controlled trials in the meta-analysis.
Participants Intervention Protocol Outcome Measured Safety
Study
MA Mindful Exercise DR
Sample Size Control Control Type Pain and Disability Adverse Events
(years) (Qualified Instructor) (wk)
160 CLBP Pain intensity (NRS),
Hall et al., (2011) [41] 44 2 × 40 min/wk, TC Wait-list 10 Passive No adverse event
TC = 80; C = 80 disability (RMDQ)
127 CLBP 1 × 60 min/wk Pain intensity (VAS),
Blödt et al., (2015) [42] 47 1 × 90 min/wk, QG 12 Active No adverse event
QG = 64; C = 63 Strengthening disability (RMDQ)
J. Clin. Med. 2019, 8, 628
176 CLBP
Teut et al., 1 × 90 min/wk, QG;
QG = 58; YG = 61 73 Waitlist 12 Passive Pain intensity (VAS) No adverse event
(2016) [43] 2 × 45 min/wk, YG
C = 57
Phattharasupharerk et al., 72 CLBP 1 × 60 min/wk plus Pain intensity (VAS),
35 Waitlist 6 Passive No adverse event
(2018) [44] QG = 36; C = 36 daily practice, YG disability (RMDQ)
43 CLBP C1: Core training C1: Active
Liu et al., (2019) [45] 74 3 × 60 min/wk, TC 12 Pain intensity (VAS) No adverse event
TC = 15; C1 = 15; C2 = 13 C2: No intervention C2: Passive
22 CLBP 2 × 60 min/wk plus disability (ODI)
Galantino et al., (2004) [46] 30–65 No treatment 6 Passive No adverse event
YG = 11; C = 11 7 × 60 min/wk (home), YG Depression (BDI)
101 CLBP C1: 1 × 75min/wk +
YG = 36; 1 × 75 min/wk plus Daily practice, C1: Active
Sherman et al., (2005) [47] 44 12 disability (RMDQ) No adverse event
C1 = 35; daily practice (home), YG aerobic exercises and strength exercise C2: Passive
C2 = 30 C2: Self-care book
60 CLBP 1 × 90 min/wk plus Pain intensity (VAS), 1 participant diagnosed
Williams et al., (2005) [48] 48 Newsletters on back pain 16 Passive
YG = 30; C = 30 5 × 30 min/wk (home), YG disability (ODI) with a herniated disc in YG
80 CLBP
Daily physical
Tekur et al., (2008) [49] YG = 40; 48 7 × 120 min/wk, YG 1 Active disability (ODI) No adverse event
movements + education
C = 40
311
90 CLBP 2 × 90 min/wk plus Pain intensity (VAS),
Williams et al., (2009) [50] 48 Waitlist 24 Passive No adverse event
YG = 43; C = 47 7 × 30 min/wk (home), YG disability (ODI)
30 CLBP 1 × 75 min/wk plus Pain intensity (VAS),
Saper et al., (2009) [51] 44 Self-care book 12 Passive No adverse event
YG = 15; C = 15 7 × 30 min/wk (home), YG disability (RMDQ)
Cox et al., 20 CLBP 1 × 75 min/wk plus Pain intensity (ABPS),
45 Self-care book 12 Passive No adverse event
(2010) [52] YG = 10; C = 10 home practice, YG disability (RMDQ)
313 CLBP 1 × 75min/wk plus Pain intensity (ABPS), 8 participants (increased pain)
Tilbrook et al., (2011) [53] 46 Self-care book 12 Passive
YG = 156; C = 157 7 × 30 min/wk (home), YG disability (RMDQ) in YG
228 CLBP C1: 1 × 75min/wk + 20 min/wk (home)
1 × 75 min/wk plus C1: Active Pain intensity (NRS) 13 participants (increased pain)
Sherman et al., (2011) [54] YG = 92; C1 = 9 1; 48 Stretching exercise 12
6 × 20 min/wk (home),YG C2: Passive disability (RMDQ) and 1 herniated disc in yoga
C2 = 45 C2: Self-care book
35days/wk,
60 CLBP 1 × 60 min/wk plus
Nambi et al., (2014) [55] 44 Exercise (strengthening 4 Active Pain intensity (VAS) 1 herniated disc in YG
YG = 30; C = 30 5 × 30 min/wk (home), YG
and stretching)
C1: 1 x 60min/wk, PT (stabilization and 9 and 14 participants (mild
320 CLBP 1 × 75 min/wk plus C1: Active Pain intensity (NRS)
Saper et al., (2017) [56] 46 aerobic exercise) 12 self-limited joint and back pain)
YG = 127; C1 = 129; C2 = 64 7 × 30 min/wk (home), YG C2: Passive disability (RMDQ)
C2: Self-care book in YG and PT, respectively
30 CLBP Pain intensity (NRS),
Kuvačić et al., (2018) [57] 34 2 × 75 min/wk, YG Pamphlet program 8 Passive Not reported
YG = 15; C = 15 disability (ODI), depression (SDS)
Note: TC = Tai Chi; YG = Yoga; QG = Qigong; PT = Physical therapy; = control group; MA = mean age; wk = week; DR = duration; CLBP = Chronic lower back pain; VAS = Visual
Analog Scale; NRS = Numeric Rating Scale; ABPS = Aberdeen Back Pain Scale; ODI = Oswestry Disability Index; RMDQ = Roland–Morris Disability Questionnaire; Self-care book refers
to reading The Back Pain Book, which emphasizing self-care management strategies for low back pain such as the causes of back pain and advice on exercising, appropriate lifestyle
modification, and guidelines for managing flare-up; Pamphlet program refers to knowledge about vertebral spine and its biomechanical aspects; BDI = Beck depression inventory;
SDS = Zung self-rating depression scale.
J. Clin. Med. 2019, 8, 628
3.3. Study Quality Assessment

Study quality for each evaluated experiment is summarized in Table 2. Overall, the included
studies demonstrated good quality (6–8 points). Notably, no studies implemented subject blinding
or therapist blinding, and only one study [56] adopted assessor blinding. Concealed allocation was
conducted in 40% of the studies, and four studies did not use intention-to-treat analysis [48–50,55].
Table 2. Methodological quality of the included studies (PEDro assessment).
Methodological PEDro Item Number

Study Score
Quality 1 2 3 4 5 6 7 8 9 10 11
Hall et al., 2011 [41] 8 Good
Blödt et al., 2015 [42] 8 Good
Teut et al., 2016 [43] 8 Good
Phattharasupharerk et al., 2018 [44] 7 Good
Liu et al., 2019 [45] 7 Good
Galantino et al., 2004 [46] 7 Good
Sherman et al., 2005 [47] 8 Good
Williams et al., 2005 [48] 6 Good
Tekur et al., 2008 [49] 7 Good
Williams et al., 2009 [50] 6 Good
Saper et al., 2009 [51] 8 Good
Cox et al., 2010 [52] 8 Good
Tilbrook et al., 2011 [53] 8 Good
Sherman et al., 2011 [54] 8 Good
Nambi et al., 2014 [55] 6 Good
Saper et al., 2017 [56] 9 Excellent
Kuvačić et al., 2018 [57] 7 Good
Studies were classified as having excellent (9–10), good (6–8), fair (4–5) or poor (<4)
Scale of item score: , present. The PEDro scale criteria are (1) eligibility criteria; (2) random allocation; (3) concealed
allocation; (4) similarity at baseline on key measures; (5) subject blinding; (6) therapist blinding; (7) assessor blinding;
(8) more than 85% follow-up of at least one key outcome; (9) intention-to-treat analysis; (10) between-group statistical
comparison for at least one key outcome; and (11) point estimates and measures of variability provided for at least
one key outcome.
3.4. Meta-Analysis of Outcome Measured
3.4.1. Pain Intensity

There were 15 studies (18 pairs of intervention vs. control comparisons since three studies [43,54,56]
included two control conditions) on pain intensity, measured by three different self-reported scales
(Visual Analog Scale (VAS), Numeric Rating Scale (NRS), and Aberdeen Back Pain Scale (ABPS)).
Based on the asymmetrical Funnel plot and the Egger’s Regression test (Egger’s regression intercept
= −3.78, p < 0.01), we removed four comparisons [44,45,55,57] and the remaining studies showed a
symmetrical Funnel plot (Figure 2) with Eggers test intercept = −1.54, p = 0.16. For the meta-analysis
of 11 studies (14 comparisons), compared with the control groups, a significant benefit on reducing
pain intensity was observed in favor of mindful exercises (SMD = −0.37, 95% CI −0.5 to −0.23,
p < 0.001, I2 = 45.9%; Figure 3). Furthermore, we performed sub-group analyses and meta-regression
for categorical variables (control type, type of mindful exercise, type of instrument, and use of allocation
concealment) and continuous variables (mean age and total time). We observed significantly different
effects on pain intensity across different types of mindful exercise (Q = 8.46, p = 0.01), with Tai Chi
(SMD = −0.75, 95% CI −1.05 to −0.46, p < 0.001) and Yoga (SMD = −0.33, 95% CI −0.47 to −0.19, p <
0.001) showing significantly decreased pain intensity, but Qigong exercise did not demonstrate such an
effect (SMD = −0.21, 95% CI −0.48 to 0.06, p = 0.12) (Table 3).
312
J. Clin. Med. 2019, 8, 628
Figure 2. Funnel plot of publication bias for pain intensity.
Figure 3. Effects of mindful exercises on pain intensity (YG = Yoga, WL = waitlist, TC = Tai Chi,
CT = core training, QG = Qigong; PT = physical therapy, SB = self-care book; SE = stretching exercise).
The red symbol represents the overall effect size in favor of mindful exercises.
3.4.2. Back-Specific Disability

Overall, there were 14 studies, including 17 pairs of mindful exercises vs. control comparisons
(because three studies [47,54,56] included two control conditions, respectively), with disability
measured by two different types of instruments (Roland–Morris Disability Questionnaire (RMDQ) and
Oswestry Disability Index (ODI)). Based on the asymmetrical Funnel plot, we removed three outlying
studies [47,49,51] and the remaining studies showed a symmetrical Funnel plot (Figure 4) with Eggers
test intercept = –0.42, p = 0.53. For the meta-analysis in 12 studies (14 pairs of mindful exercises vs.
control comparisons), compared with the control groups, the aggregated result showed a significant
benefit in favor of mindful exercises on reducing disability (SMD = −0.39, 95% CI −0.49 to −0.28,
p < 0.001, I2 = 0%; Figure 5). We performed sub-group analyses and meta-regression for categorical
variables (control type, type of mindful exercise, type of instrument, and use of allocation concealment)
and continuous variables (mean age and total time) (Table 3). No significant differences were observed.
313
J. Clin. Med. 2019, 8, 628
Figure 4. Funnel plot of publication bias for disability.
Figure 5. The effect of mindful exercises on disability (YG = Yoga, ASE = Aerobic and strength exercise,
SB = self-care book, SE = stretching exercise).The red symbol below represents the overall effect size in
favor of mindful exercises.
314
Table 3. The effect of mind-body exercise in moderator analysis.
Test for Between-Group

No. of 95% Confidence I2 %
Categorical Moderator Outcome Covariates SMD Hoterogeneity
Studies/Comparisons Interval
Q-Value df(Q) p-Value
Active 7 −0.40 -0.48 to -0.20 53.2 %
Pain intensity 0.08 1 0.78
Passive 7 -0.35 −0.46 to −0.21 46.5%
Control Type
J. Clin. Med. 2019, 8, 628
Active 4 −0.28 −0.47 to −0.09 0%

Disability 1.62 1 0.20
Passive 10 −0.43 −0.55 to −0.31 0%
Yoga 10 −0.33 −0.47 to −0.19 33.7%
Pain intensity TC 2 −0.75 −1.05 to −0.46 0% 8.46 2 0.01*
Qigong 2 −0.21 −0.48 to 0.06 10.0%
Mindful Type
Yoga 11 −0.38 −0.50 to −0.26 0%
Disability TC 1 −0.41 −0.72 to −0.10 0% 0.16 2 0.92
Qigong 2 −0.47 −1.09 to 0.14 77.2%
ABPS 2 −0.21 −0.42 to 0.01 0%
Pain intensity VAS 7 −0.43 −0.68 to −0.18 50.5% 2.1 2 0.35
Instruments NRS 5 −0.38 −0.59 to −0.17 60.1%
RMDQ 10 −0.38 −0.49 to −0.27 0%
ODI 4 −0.47 −0.76 to −0.18 0%
Yes 11 −0.33 −0.46 to −0.19 39.5%
Pain intensity 1.19 1 0.28
No 3 −0.59 1.05 to −0.13 50.9%
Allocation Concealment
315
Yes 9 −0.35 −0.46 to −0.24 0%
No 5 −0.56 −0.80 to −0.31 0%
Continuous moderator Outcome No. of studies/comparisons β 95% Confidence Interval Q-value df(Q) p-value
Pain intensity 14 −0.00108 −0.01080 to 0.00865 0.05 1 0.83
Age
Disability 14 0.02454 −0.00706 to 0.05614 2.32 1 0.13
Pain intensity 14 0.00002 −0.00007 to 0.00012 0.22 1 0.64
Total Time
Disability 14 −0.00002 −0.00012 to 0.00009 0.10 1 0.75
VAS = Visual Analog Scale; RMDQ = Roland-Morris Disability Questionnaire; SMD = Standardized Mean Difference; TC = Tai Chi; * p < 0.01.
J. Clin. Med. 2019, 8, 628
4. Discussion
Mindful exercises are increasingly accepted by clinicians worldwide as an alternative therapy
for chronic disease symptomatic management. To the best of our knowledge, this is the first
systematic review to comprehensively evaluate the existing literature regarding the safety and pain-
and disease-specific effects of three commonly practiced mindful exercises (Tai Chi, Qigong, and Yoga)
among adults with CLBP. Our findings indicated that mindful exercises may be effective in reducing
pain intensity and disability among CLBP patients. More importantly, the beneficial effects of mindful
exercises were observed comparing to both non-active and active controls. Notably, several Yoga
interventions induced varied adverse events (e.g., injury).
4.1. Pain Intensity

Overall, mindful exercises may be effective in reducing pain intensity level, with a small
intervention effect (SMD = −0.37). However, we observed non-significant effects on this outcome in
five comparisons [42,43,48,51,52] and marginally significant effects in three comparisons [43,47,53].
Such results may be attributed to inadequacy of weekly instructor-led training time (75 to 90
min) [42,43,47,53], relatively small sample size [48,51,52] (20 to 60 participants), and/or direct comparison
to active controls (strengthening or stretching exercise) [42,47]. When compared with an active control
alone, mindful exercises showed significantly reduced pain intensity (SMD = −0.40, p < 0.001).
This suggests that mindful exercise may be more beneficial for pain management than conventional
exercise (strengthening and/or stretching exercise) and guideline-endorsed (core training or physical
therapy) programs. Furthermore, results from the sub-group analyses indicated that, when compared
to Yoga and Qigong, Tai Chi appeared to have a superior effect on pain relief. Such positive intervention
effects reached a moderate level (SMD = −0.75). Tai Chi emphasizes neutral spine or standing with
upright posture during performance, providing an opportunity to strengthen core muscles (similar to
a guideline-endorsed core training program) to reduce pain intensity. Additionally, a previous RCT by
Hall [58] indicated that Tai Chi can reduce pain-catastrophizing, which partially mediates the effect
of Tai Chi on pain intensity among adults with CLBP. Conversely, adverse events (increased pain,
reduced range of motion at joints, and/or herniated disc) were reported in several Yoga intervention
studies but not in Tai Chi studies. This is likely due to the Yoga routine, which involves movements
of bending forward and backwards at the low back, which may initiate or exacerbate pain intensity.
Taken together, Tai Chi may be a more suitable mindful exercise in rehabilitation programs for CLBP
rather than Yoga.
4.2. Back-Specific Disability

In this meta-analysis, we observed a small overall positive effect (SMD = −0.39) of mindful exercise
on disability. Of the 12 studies (including 14 comparisons), six comparisons (Qigong vs. waitlist,
Tai Chi vs. waitlist, Yoga vs. aerobic plus strength exercises, Yoga vs. Waitlist, Yoga vs. self-care
book, Yoga vs. stretching exercise, and Yoga vs. waitlist) [41,44,47,50,53,54] showed significant effects
on CLBP-specific disability, whereas the other eight [42,46,48,51,52,54,56,57] demonstrated positive
effects. Throughout the 12-week intervention period, weekly instructor-based training length ranged
from 75 to 90 min in Qigong [42] and Yoga [54,56], which may not be sufficient to achieve significant
reductions in disability risk. Notably, Neiyanggong, as one type of Qigong exercise, is not as popular
as Baduanjin and Wuqinxi Qigong. Thus, it presumably takes beginners much longer to understand
the principle and movement concepts, particularly during the initial stage of motor learning (cognitive
stage) [59]. A 90-min session per week during a 12-week Neiyanggong intervention may not be
sufficient to maximize the potential benefits of this modality of exercise. Likewise, movements in Yoga
routine are relatively complex and require a certified instructor, and self-practice at home may lead to
incorrect movement patterns, which may have contributed to the deterioration in disability or caused
the observed adverse events (increased pain, herniated disc, and/or reduced range of motion at joints)
316
J. Clin. Med. 2019, 8, 628
reported in the five Yoga intervention studies [48,53–56]. Second, three studies included relatively
small sample sizes of 20 [52], 30 [51] and 60 participants [48], which may have affected the power of
detecting significant differences on disability risk.
4.3. Strengths and Limitations for Future Research

Strengths of this systematic review are as follows: (1) we provide a comprehensive review
regarding the effectiveness of mindful exercises on CLBP disease-specific symptoms; (2) we were the
first to include three popular mindful exercises; (3) we compared mindful exercises with active controls
(conventional exercises and guideline-endorsed physical therapy); and (4) we evaluated the safety
of mindful exercises in adults with CLBP [60,61]. Several limitations should be considered: (1) this
review only included English-language studies, which possibly excluded Chinese-language journals
that may be more likely to publish Tai Chi and Qigong studies; (2) we limited our meta-analysis to
pain intensity and disability. We were not able to meta-analyze data on depressive symptomology
(and other related outcomes) due to fewer than four studies reporting data on this outcome. Thus,
future studies should include psychological outcome measures; (3) blinding of assessors was only used
in one study (blinding of instructor and participants are, however, unrealistic), and it remains unclear
whether greater expectations were associated with reduced pain intensity and disability in the mindful
exercise groups; (4) some studies did not use “intention to treat analysis” and “allocation concealment”,
which possibly overestimated the pooled effect size; (5) none of studies used follow-up assessments,
so it is difficult to determine how long the beneficial effects of mindful exercise interventions lasted in
adults with CLBP; (6) previous studies suggest that different brain mechanisms are associated with
different mindful exercises, thus, future studies should comparatively investigate different mind-body
exercises as well as their underlying mechanisms [62,63].
5. Conclusions
Findings of our systematic review suggest that mindful exercises (Yoga, Tai Chi, and Qigong)
may be beneficial for CLBP symptomatic management, irrespective of non-control comparison or
active control comparison (conventional exercises, core training, and physical therapy programs).
The potential of Tai Chi as a routine non-pharmacological approach for CLBP needs to be rigorously
evaluated in future studies. Importantly, training in these mindful exercises should be implemented
with certified instructors, to ensure quality of movement and injury prevention. Before definitive
conclusions can be drawn, future work is needed that employs more robust study designs and
implements long-term follow-up assessments.
Author Contributions: L.Z., Y.J.Z., A.Y., K.W.C., L.Y., P.D.L., T.X., and H.L. contributed to the conception and
design of the review. Y.J.Z. and L.Z. applied the search strategy. L.Z. and Y.J.Z. applied the selection criteria. L.Z.,
Y.J.Z. and H.L. completed assessment of risk of bias. All authors analyzed and interpreted the data. All authors
wrote this manuscript. All authors edited this manuscript. L.Z., Y.J.Z., T.X., and H.K. are responsible for the
overall project.
Acknowledgments: The leading author would like to thank his family members (wife, son, daughter, and parents)
for their consistent support.
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www.mdpi.com ISBN 978-3-03943-844-0

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Rehabilitation for

ISBN 978-3-03943-843-3 (Hbk)

About the Editors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii

Kelly Ickmans, Lennard Voogt and Jo Nijs

Jo Nijs, Kelly Ickmans, David Beckwée and Laurence Leysen

Lauren E. Harrison, Joshua W. Pate, Patricia A. Richardson, Kelly Ickmans, Rikard K.

Michele Sterling, Rutger M. J. de Zoete, Iris Coppieters and Scott F. Farrell

Adrián Pérez-Aranda, Francesco D’Amico, Albert Feliu-Soler, Lance M. McCracken, Marı́a T.

Manuel Albornoz-Cabello, Jose Antonio Sanchez-Santos, Rocio Melero-Suarez, Alberto

Zoë C. Franklin, Paul S. Holmes and Neil E. Fowler

Elena Dragioti, Mathilda Björk, Britt Larsson and Björn Gerdle

Received: 14 November 2019; Accepted: 18 November 2019; Published: 21 November 2019

J. Clin. Med. 2019, 8, 2042; doi:10.3390/jcm8122042 1 www.mdpi.com/journal/jcm

Received: 3 June 2020; Accepted: 4 June 2020; Published: 9 June 2020

Keywords: rehabilitation; chronic pain; inﬂammation

J. Clin. Med. 2020, 9, 1793; doi:10.3390/jcm9061793 5 www.mdpi.com/journal/jcm

2. Disease-Based Osteoarthritis Treatment Oﬀers Modest Eﬀect Sizes

3. Personalized Activity Self-Management for Patients with Osteoarthritis

4. Implementation Barriers for a Personalized Activity Self-Management Approach

Table 1. Proposed paradigm shift from disease-based treatment to personalized activity

5. Pain Neuroscience Education + Behavioral Graded Activity = BGA+

Received: 15 July 2019; Accepted: 16 August 2019; Published: 21 August 2019

Keywords: chronic pain; children pain rehabilitation; best evidence

J. Clin. Med. 2019, 8, 1267; doi:10.3390/jcm8091267 11 www.mdpi.com/journal/jcm

2. State of the Art of Rehabilitation for Pediatric Chronic Pain

Table 1. Best Evidence for Rehabilitation in Pediatric Chronic Pain.

Evidence Supporting Interventions Examples of Resources

Evidence Supporting Interventions Examples of Resources

2.1. Pain Related Education

Pain Science Education

2.2. Physiological Self-Regulation Training

Mindfulness-Based Stress Reduction and Yoga

2.3. Cognitive Skills Training

2.4. Behavioral Exposure

2.5. Parent Coaching

2.6. Physical Therapy

2.7. Occupational Therapy

2.8. Addressing Comorbidities

2.9. Interdisciplinary Outpatient Pain Treatment

2.10. Intensive Interdisciplinary Pain Treatment

2.11. Emerging Pain Treatment Intervention Formats

2.12. Summary of Rehabilitative Treatments for Pediatric Chronic Pain

3. Promising Directions for Clinical Practice

4. Promising Directions for Research

Received: 5 June 2019; Accepted: 4 July 2019; Published: 5 July 2019

Keywords: cancer; pain; rehabilitation; exercise

J. Clin. Med. 2019, 8, 979; doi:10.3390/jcm8070979 31 www.mdpi.com/journal/jcm

shoulder due to having 4) Resistance exercises (McNeely et al 2004

cognitive behavioural - no stat. sign. diﬀerence among 3

2.2. Speciﬁc Exercise Therapy

2.3. Manual Therapy

2.4. General Exercise Therapy

2.5. Mind-Body Exercise Therapy

3. Promising Directions for Clinical Practice

4. Promising Directions for Research

Received: 6 June 2019; Accepted: 16 July 2019; Published: 19 July 2019

Keywords: pain neuroscience; musculoskeletal pain; rehabilitation medicine; physiotherapy; lifestyle

J. Clin. Med. 2019, 8, 1063; doi:10.3390/jcm8071063 51 www.mdpi.com/journal/jcm

2. State of the Art