Background: The treatment of non-specific chronic low back pain is often based on three different models regarding the development and maintenance of pain and especially functional limitations: the deconditioning model, the cognitive behavioral model and the biopsychosocial model.

Objective. To determine the efficacy of combined spa-exercise therapy in addition to standard treatment with drugs and weekly group physical therapy in patients with ankylosing spondylitis (AS). Methods. A total of 120 Dutch outpatients with AS were randomly allocated into 3 groups of 40 patients each. Group 1 (mean age 48 ؎ 10 years; male:female ratio 25:15) was treated in a spa resort in Bad Hofgastein, Austria; group 2 (mean age 49 ؎ 9 years; male:female ratio 28:12) in a spa resort in Arcen, The Netherlands. The control group (mean age 48 ؎ 10 years; male:female ratio 34:6) stayed at home and continued their usual drug treatment and weekly group physical therapy during the intervention weeks. Standardized spa-exercise therapy of 3 weeks duration consisted of group physical exercises, walking, correction therapy (lying supine on a bed), hydrotherapy, sports, and visits to either the Gasteiner Heilstollen (Austria) or sauna (Netherlands). After spa-exercise therapy all patients followed weekly group physical therapy for another 37 weeks. Primary outcomes were functional ability, patient's global well-being, pain, and duration of morning stiffness, aggregated in a pooled index of change (PIC). Results. Analysis of variance showed a statistically significant time-effect (P < 0.001) and time-by-treatment interaction (P ‫؍‬ 0.004), indicating that the 3 groups differed over time with respect to the course of the PIC. Four weeks after start of spa-exercise therapy, the mean difference in PIC between group 1 and controls was 0.49 (95% confidence interval [CI] 0.16 -0.82, P ‫؍‬ 0.004) and between group 2 and controls was 0.46 (95% CI 0.15-0.78, P ‫؍‬ 0.005). At 16 weeks, the difference between group 1 and controls was 0.63 (95% CI 0.23-1.02, P ‫؍‬ 0.002) and between group 2 and controls was 0.34 (95% CI ؊ 0.05-0.73; P ‫؍‬ 0.086). At 28 and 40 weeks, more improvement was found for group 1 compared with controls (P ‫؍‬ 0.012 and P ‫؍‬ 0.062, respectively) but not for group 2 compared with controls. Conclusion.In patients with AS, a 3-week course of combined spa-exercise therapy, in addition to drug treatment and weekly group physical therapy alone, provides beneficial effects. These beneficial effects may last for at least 40 weeks.

Patients' initial beliefs about the success of a given pain treatment are shown to have an important influence on the final treatment outcome. The aims of the paper are to assess determinants of patients' treatment expectancy and to examine the extent to which treatment expectancy predicts the short-term and long-term outcome of cognitive-behavioral treatment of chronic pain. This study employs the data of 2 pooled randomized clinical trials evaluating the effectiveness of cognitive-behavioral interventions for 171 patients with fibromyalgia and chronic low back pain. Pretreatment and posttreatment expectancy were measured by a short questionnaire, which was based on the procedure by Borkovec and Nau. Four composite outcome variables (pain coping and control, motoric behavior, negative affect, and quality of life) were measured before and after the intervention and at 12 months follow-up. Furthermore, several patient characteristics were taken into account. Patients with higher treatment expectancies significantly received less disability compensation and were less fearful. A regression model of 3 factors (better pain coping and control, active and positive interpretation of pain, and less disability compensation) significantly explained 10% of the variance in pretreatment expectancy. Pretreatment expectancy significantly predicted each of the 4 outcome measures immediately after treatment and at 12 months follow-up. This study corroborates the importance of treatment expectation before entering a cognitive-behavioral intervention in patients with chronic musculoskeletal pain.

Several treatment principles for the reduction of chronic low back pain associated disability have been postulated. To examine whether a combination of a physical training and an operant-behavioral graded activity with problem solving training is more effective than either alone in the long-term, a cluster randomized controlled trial was conducted. In total 172 patients, 18-65 years of age, with chronic disabling non-specific low back pain referred for rehabilitation treatment, were randomized in clusters of four consecutive patients to 10 weeks of aerobic training and muscle strengthening of back extensors (active physical treatment; APT), 10 weeks of gradual assumption of patient relevant activities based on operant-behavioral principles and problem solving training (graded activity plus problem solving training; GAP), or APT combined with GAP (combination treatment; CT). The primary outcome was the Roland Disability Questionnaire adjusted for centre of treatment, cluster, and baseline scores. Secondary outcomes were patients' main complaints, pain intensity, self-perceived improvement, depression and six physical performance tasks. During the one-year follow-up, there were no significant differences between each single treatment and the combination treatment on the primary outcome, the Roland Disability Questionnaire. Among multiple other comparisons, only one significant difference emerged, with GAP and APT showing higher self-perceived improvement than CT. We conclude that the combination treatment integrating physical, graded activity with problem solving training is not a better treatment option for patients with chronic low back pain.

Purpose. To study the effects of adding supervised group physical therapy to unsupervised individualized therapy in trnkylosing spondylitis. Methods. One hundred forty-four patients were randomized to exercises at home, or the same plus weekly group physical therapy for 9 months. Endpoints were spinal mobility, fitness (maximum work capacity by ergometry), functioning (Sickness Impact Profile, Health Assessment Questionnaire for the Spondylarthropathies, and Functional Index), and patient's global assessment of change on a 10-cm visual analogue scale. Resiults. Thoracolumbar flexion and extension increased by an average of 0.5 cm (9%) after home exercises, and by 0.9 cm (2670) after group therapy. Maximum load in ergometry decreased by 2 W (2%) after home exercises, but increased by 7 W (4%) after group therapy. Global assessment improved by 0.3 (6%) after home exercises, and by 2.7 (34%) after group therapy. These three differences were statistically significant. There were no significant differences in chest expansion, cervical rotation, or the self-assessmenis of functioning. Conclusions. Group physical therapy proved superior to individualized therapy in improving thoracoluntbar mobility and fitness, and had an important effect on global health reported by the patients.

Objective. To evaluate the cost effectiveness and cost utility of a 3-week course of combined spa therapy and exercise therapy in addition to standard treatment consisting of antiinflammatory drugs and weekly group physical therapy in ankylosing spondylitis (AS) patients. Methods. A total of 120 Dutch outpatients with AS were randomly allocated into 3 groups of 40 patients each. Group 1 was treated in a spa resort in Bad Hofgastein, Austria; group 2 in a spa resort in Arcen, The Netherlands. The control group stayed at home and continued their usual activities and standard treatment during the intervention weeks. After the intervention, all patients followed weekly group physical therapy. The total study period was 40 weeks. Effectiveness of the intervention was assessed by functional ability using the Bath Ankylosing Spondylitis Function Index (BASFI). Utilities were measured with the EuroQoL (EQ-5D utility ). A time-integrated summary score defined the clinical effects (BASFI-area under the curve [AUC]) and utilities (EQ-5D utility -AUC) over time. Both direct (health care and non-health care) and indirect costs were included. Resource utilization and absence from work were registered weekly by the patients in a diary. All costs were calculated from a societal perspective. Results. A total of 111 patients completed the diary. The between-group difference for the BASFI-AUC was 1.0 (95% confidence interval [95% CI] 0.4 -1.6; P ‫؍‬ 0.001) for group 1 versus controls, and 0.6 (95% CI 0.1-1.1; P ‫؍‬ 0.020) for group 2 versus controls. The between-group difference for EQ-5D utility -AUC was 0.17 (95% CI 0.09 -0.25; P < 0.001) for group 1 versus controls, and 0.08 (95% CI 0.00 -0.15; P ‫؍‬ 0.04) for group 2 versus controls. The mean total costs per patient (including costs for spa therapy) in Euros (€) during the study period were €3,023 for group 1, €3,240 for group 2, and €1,754 for the control group. The incremental cost-effectiveness ratio per unit effect gained in functional ability (0 -10 scale) was €1,269 (95% CI 497-3,316) for group 1, and €2,477 (95% CI 601-12,098) for group 2. The costs per quality-adjusted life year gained were €7,465 (95% CI 3,294 -14,686) for group 1, and €18,575 (95% CI 3,678 -114,257) for group 2. Conclusion. Combined spa-exercise therapy besides standard treatment with drugs and weekly group physical therapy is more effective and shows favorable cost-effectiveness and cost-utility ratios compared with standard treatment alone in patients with AS.

This study examined the role of work-related, psychosocial and psychological factors in predicting functional and social disability in working employees. In a cross-sectional design, 890 working employees (reporting at least 1 day of back pain during the past year) completed self-report measures of back pain, disability, pain-related fear, negative and positive affectivity, job satisfaction, job stress and physical work load. Regression analyses revealed that pain intensity was a strong predictor of functional (beta = .69, p < .001) and social disability (beta = .67, p < .001). Fear of (re)injury due to movement (beta = .25, p < .001; beta = .28, p < .001) had additional predictive value in both models. Further, (singular) mediation tests indicated that fear for (re)injury partially mediated the relation between pain intensity and disability, and between negative affectivity and disability. Finally, path analyses revealed both fear and pain intensity as mediators between negative affectivity and disability. Overall, our findings point at the relevance of the cognitive-behavioral model of avoidance in occupational settings.

This cross-sectional questionnaire study investigated the role of pain (pain severity, radiating pain), work characteristics (physical workload, job stressors, job satisfaction), negative affect and pain-related fear in accounting for low back pain (LBP) and sick leave (SL) in 1294 employees from 10 companies in Belgium and the Netherlands. An increased risk for short-term LBP (1-30 days during the last year) was observed for workers reporting high physical workload (OR=2.39), high task exertion (OR=1.63) and high negative affect (OR=1.03). For prolonged LBP (>30 days during the last year) severe pain (OR=13.03), radiating pain (OR=2.37) and fear of work-related activities (OR=3.17) were significant risk factors. A lack of decision latitude decreased the risk of long-term LBP (OR=0.39). Short-term SL (1-30 days during the last year) was associated with severe pain (OR=2.83), high physical workload (OR=2.99) and high fear of movement/(re)injury (OR=1.88). A lack of decision latitude increased the risk of short-term SL (OR=1.92). Long-term SL (>30 days during the last year) was associated with radiating pain (OR=3.80) and high fear of movement/(re)injury (OR=6.35). A lack of co-worker support reduced the risk of long-term SL (OR=0.27). These results suggest that physical load factors are relatively more important in the process leading to short-term LBP and short-term SL, whereas job stressors, severe pain, radiation, and pain-related fear are more important in determining the further course and maintenance of the inability to work. The potential implications of these findings for primary and secondary prevention, and occupational rehabilitation are discussed.