Karen L Barker1,2*, Leila Heelas1, Elaine Buchanan1 and Fran Toye1
1Physiotherapy Department, Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Trust, Oxford, OX3 7HE, UK
2Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Biomedical Research Unit, University of Oxford, Windmill Road, Oxford OX3 7LD, UK
Received: 29 June, 2014; Accepted: 06 September, 2014; Published: 08 September, 2014
Karen L Barker PhD, FCSP, Clinical Director, Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Trust, Windmill Road, Oxford, OX3 7HE, UK, Tel: 00 44 (0) 1865 738080; Fax: 00 44 (0) 1865 738043; Email:
Barker KL, Heelas L, Buchanan E, Toye F (2014) Which Pain Rehabilitation Programme Should Patients With Chronic Back Pain Attend? – A Practical Example of a Service Evaluation Based Upon Implementing Research Findings into Clinical Practice. J Nov Physiother Phys Rehabil 1(1): 032-038. DOI: 10.17352/2455-5487.000007
© 2014 Barker KL, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Pain rehabilitation; Chronic back pain; Physical therapy
Background: To evaluate a service reconfiguration of pain rehabilitation programmes for chronic back pain using three programmes of differing intensity and duration and a clinical algorithm. This study describes the outcomes for each programme for three consecutive cohorts.
Method: Non randomised observational study of 120 consecutive patients with chronic pain treated by a Physiotherapy Department of a Specialist Orthopaedic and Rehabilitation hospital. Three different pain rehabilitation programmes each comprising of multidisciplinary rehabilitation with varying intensity and duration of content were compared for clinical and cost efficacy. The main outcomes used were Oswestry Disability Index (ODI), Pain visual analogue score (VAS), pain catastrophising scale (PCS), pain self efficacy questionnaire (PSEQ), Tampa scale for kinesiophobia (TSK) and physical tests of timed sit to stand and 5 minute walk test.
Results: Analysis of changes within groups was by Wilcoxon signed rank tests and found patients attending the ‘gold standard' Functional Restoration Programme showed statistically and clinically significant improvements in mean change scores for VAS, PCS, TSK, PSEQ, sit to stand and 5 minute walk test - p<0.001; with effect sizes for the different outcomes ranging from 0.2-1.19. For the shorter Active Rehabilitation Programme there were significant improvements all outcomes except TSK and sit to stand (p0.004), with effect sizes varying from 0.48-0.81. For the Short Management Programme there were significant improvements all outcomes with effect sizes ranging from 0.18-1.14.
Conclusion: This research uses a novel approach where an existing service was redesigned adhering to key principles but varying intensity and duration and using a clinical algorithm to determine treatment allocation in order to translate research based findings into clinical practice.
Seventy five percent of patients with back pain who consult a doctor will have symptoms one year later and about 30% of these will develop persistent disabling pain [1,2]. Physical rehabilitation incorporating a psychological approach has been shown to improve functional ability in patients with persistent back pain [3-7]. The NICE Clinical Guidance for the Management of Low Back Pain  recommends referral for a combined physical and psychological treatment programme for people with high disability and /or significant psychological distress, who have already received a less intensive treatment. However, there is a lack of sufficient resources to deliver long duration, multidisciplinary programmes [9,10].
Since the mid 1990's we have provided a functional restoration rehabilitation programme (FRP) that is physiotherapy led using cognitive behavioural principles, supported by a clinical psychologist. The results from this original programme were reported by Frost et al. , and Fairbank et al.  and long term results in Mannion et al. . The success of the programme led to a tenfold increase in referrals to the programme, with no additional resources. We therefore looked at how we could adapt the ‘gold standard' programme we had originally used, to make it affordable and enable us to deliver it within the resources available, allowing for normal financial and commissioning constraints.
We reviewed the literature and published clinical guidelines about different types of physiotherapy led pain rehabilitation programmes. The evidence supports multi-disciplinary cognitive-behavioural and exercise rehabilitation programmes [13-17]. We compared the profile of patients reported in the literature to the patients referred to our own pain management services. Based on the published guidelines we identified that many of our patients could potentially be treated within programmes of shorter duration or lesser intensity. Therefore, we decided to reconfigure our clinical service to offer three types of pain rehabilitation programme. In addition to FRP, we therefore introduced two new programmes– Active Rehabilitation Programme (ARP) and Short Management Programme (SMP), with a selection algorithm to allocate patients to each programme. These new shorter programmes slightly differed in focus. SMP was aimed at patients who were working but who may have difficulties in work or leisure activities and the ARP was for more highly disabled patients that were likely to find the higher intensity FRP too physically demanding. We designed an algorithm to allocate patients to the different programmes (Table 1).
Our primary aim was to evaluate development to a clinical service; this paper reflects an evaluation of our standard clinical services, rather than a stand-alone research study. As such, it was not appropriate to randomise patients. We aimed to test the screening algorithm devised to characterise patients and to test the assumptions behind the re-designed programme using a non randomised observational study. Secondly, we sought to compare the cost of delivering the different rehabilitation programmes.
We hypothesised that whilst there were differences in the patient characteristics, intensity of programme and programme cost, there would still be clinically relevant improvements in patients' outcomes from each of the programmes.
Patients were eligible to attend the rehabilitation programmes if they had disabling chronic non-specific low back pain of at least one year's duration and pain that was related to unhelpful cognitions.
Patients were excluded from participating in a rehabilitation group if they had co-existing health problems that precluded exercise, e.g. unstable cardiac conditions, active inflammatory disease, were under 18 years of age or were assessed by a clinical psychologist as unable to participate in a group setting, if they were awaiting/receiving further investigation and/or treatment for their pain problem or awaiting/receiving further investigation/treatment for co-existing health problems which would impact on group participation.
Patients not eligible to attend the rehabilitation programmes were offered treatment on an individual basis.
We included 40 consecutive patients attending each programme (n = 120).
As this was a service evaluation we did not seek ethical committee approval, however, all patients gave written consent for their data to be used for evaluation and audit purposes.
Screening algorithm and programme selection
A screening algorithm was developed which assessed patients based upon clinical characteristics and scores on questionnaires for function and mental status completed by the patient.
All patients attended a one hour assessment visit where they discussed the programme options with their physiotherapist. Patients were allocated to a particular programme based on: their level of functional disability as scored on the Oswestry Disability Index  and 5-minute walk-test (REF); work status; programme preference; severity or control of their pain; level of anxiety or depression as scored on the Hospital Anxiety and Depression scale . Many of these same measures were also used at the end of the programmes to evaluate the effectiveness.
Further details are summarised in table 1.
All of the programmes shared a similar philosophy – to encourage patients to adopt a positive approach to managing their pain, whilst decreasing functional disability and increasing the patients' confidence in their ability to manage their condition on a day to day basis. The programme was predominantly physiotherapy led, with input from a clinical psychologist and a physician. The programmes varied in duration and in intensity. The outcome measure data before and after the programmes was collected by a physiotherapy assistant.
Functional Restoration Programme (FRP): Each group had a maximum of 8 people. The programme ran for 6 hours a day for 4 days /week for 3 weeks (total of 72 hours). The patients spent approximately three hours per day engaged in activities including stretching, graded strengthening, aerobic conditioning, core stability based exercises, graded exposure to feared activities, circuit based (pacing) exercise, hydrotherapy and relaxation.
The remaining three hours were spent in educational or discussion sessions which included such topics as: how to increase activity, how to exercise safely, understanding pain which persists, sleep, healthy eating, medication, employment advice, exploring common worries and concerns, the role and limitations of investigations, plans for possible setbacks, how family can help, posture and lifting and leisure and recreation.
Goals were set according to S.M.A.R.T principles and divided to short term i.e. daily and weekly and long term goals monthly and yearly.
Active Rehabilitation Programme (ARP): Each group had a maximum of 8 people. The programme consisted of 8 sessions each lasting 5 hours and occurred once a week (total of 40 hours). Again the content was split between activities (exercises, hydrotherapy and relaxation) and education or discussion sessions. Generally the programme aimed to help patients explore new ways of managing persisting pain, improve confidence, help patients understand why pain persists, increase general fitness and reduce frustration and anxiety.
Short Management Programme (SMP): Each group had a maximum of 10 people. The programme consisted of 6 sessions, each lasting 2 hours, occurring on a weekly basis (total of 12 hours). Again the programme consisted of activities (exercises, hydrotherapy and relaxation) and education or discussion sessions.
All three programmes used paced exercise, individually tailored to the patients' ability and included a combination of stretching exercises, general muscle strengthening, spine stabilisation exercises, endurance and low impact aerobic exercise and relaxation. For the FRP and ARP programmes there were also sessions in the hydrotherapy pool. Full details of the programme are included in Appendix 1.
All patients kept exercise log diaries and utilised a shared goal setting approach. At the end of each programme patients agreed both short and long term goals. Patients were reviewed at two further appointments after the programme where their progress was reviewed against their set goals and also by change from their baseline outcome assessment measures.
Before being allocated to a programme patients completed screening questionnaires of Pain visual analogue scale, Oswestry Diasability Index (ODI), Tampa scale for kinesiophobia (TSK) and a 5 minute walking test which was used in the algorithm to inform the programme selection. On starting each programme and 6 months after completion, patients completed these standard outcome assessments with the addition of the pain catastrophising scale (PCS), pain self-efficacy questionnaire (PSEQ) and physical tests of timed sit to stand. Pain was recorded using a 100mm VAS recording patient's average pain intensity level .
The Tampa Scale for Kinesiophobia (TSK) was used to assess the subjective rating of kinesiophobia or fear of movement. It is a 17 item self-completed questionnaire developed to "discriminate between non-excessive fear and phobia among patients with chronic musculoskeletal pain." The range of scores is from 17 to 68 where the higher scores indicate an increasing degree of kinesiophobia .
The Pain Catastrophising Scale was used to assess the three components of catastrophising: rumination, magnification and helplessness, defined as "an exaggerated negative mental set brought to bear during actual or anticipated painful experience". It consists of 13 items, scored on a 0-5 scale with a range of scores from 0-52. A PCS of 30 or more is considered to represent a clinical level of catastrophising. These scales have good reported clinometric properties and are reported to be valid, reliable and responsive in a chronic low back pain population [22,23].
The Pain Self Efficacy Questionnaire was used to assess the confidence people in pain have in performing activities while in pain. It is a 10 item questionnaire scored on a 7 point scale with a range of scores from 0-60. Higher scores indicate greater self-efficacy. Low PSEQ scores of < 20 are associated with an unwillingness to participate in activities . It is reported to have good content and construct validity, good internal consistency and to be reliable .
Functional physical tests - 5 minute walking distance and 1 minute standing up and sitting down from a chair were used to assess those aspects of physical performance most relevant to everyday activities.
Non-parametric statistics were used to compare outcome measures within the groups. Data were analysed using Wilcoxon's signed rank test and the statistical package SPSS 20 for Windows. Effect sizes (Hedges' g) were calculated for each outcome to show relative effectiveness of the programmes .
Statistical significance was set at the p<0.05 level.
Distribution of patients
The proportion of patients allocated into each of the different groups from the entire population over a year using the clinical algorithm resulted in a distribution between the programmes of 45% to FRP, 30% ARP and 25% SMP. We have reported data from the first 40 consecutive patients in each programme.
The baseline characteristics of the participants are described in table 2.
Adherence to algorithm
After completion of the programme the characteristics of the participants were checked to see that they met the criteria agreed in the selection algorithm. The compliance with the algorithm was 100%.
Patients attending the ‘gold standard' FRP programme showed statistically and clinically significant improvements in mean change scores for PCS (20.4 to 11.6), TSK ( 41.1 to 32.6) , PSEQ (28.9 to 38.2), and 5 minute walk test ( 228m to 306 m) – all p<0.001. They demonstrated a smaller decrease in VAS pain score from 6.12 to 4.82 (p 0.004), sit to stand 13.4 to 15.4 (p 0.009) and ODI from 41.7 to 38.3 (p 0.118).
For the ARP there were significant improvements in the mean change for VAS 8.7 to 7.45 (p0.000), PSEQ 24.2 to 32.07 (p 0.000) PCS 25.8 to 18.2; (p 0.000), ODI 52.4 to 45.9 (p0.000) and sit to stand (5.25 to 6.05; p0.001). Other outcomes were not statistically significant.
For the SMP there were significant improvements in the mean change for VAS 5.92 to 4.87 (p 0.000), PSEQ 29.9 to 36.1 (p 0.000), TSK 39.2 to 37.4 (p0.001), PCS (24.5 to 17.9; p0.000), sit to stand (15. to 17.5; p0.004) and walking (281 to 306m; p0.016) (Table 3).
We have not attempted to compare the relative efficacy of the three treatment approaches as the algorithm used to allocate patients to each programme ensured that the baseline characteristics of the patients in terms of pain and disability were very different; for example prior to treatment the mean pain VAS for the FRP was 6.12, but 8.7 in the ARP and the ODI was 41 for FRP but 52 for ARP. Effect sizes for each outcome were calculated to show the efficacy of the programmes – see figure 1.
- Waddell G, Feder G, McIntosh A, Lewis M, Hutchinson A (1996) Low back pain: clinical guidelines and evidence review. London: Royal College of General Practitioners.
- Croft PR, Macfarlane GJ, Papageorgiou AC, Thomas E, Silman AJ (1998) Outcome of low back pain in general practice: a prospective study. BMJ 316: 1356–1359.
- Frost H, Lamb SE, Shackleton C (2000) Functional restoration programme for chronic low back pain. A prospective outcome study. Physiotherapy 86: 285-293.
- Hay E, Mullis R, Lewis M, Vohora, K (2005) Comparison of physical treatments versus a brief pain-management programme for back pain in primary care: a randomised clinical trial in physiotherapy practice. Lancet 365: 2024-2030.
- Critchley DJM, Ratcliffe JP, Noonan SB, Jones RHF, Hurley MVP (2007) Effectiveness and Cost-Effectiveness of three types of physiotherapy used to reduce chronic low back pain disability: A pragmatic randomized trial with economic evaluation. Spine 32: 1474-1481.
- Ewert T, Limm H, Wessels T, Rackwitz B, Von Garnier K, et al. (2009) The comparative effectiveness of a multimodal program versus exercise alone for the secondary prevention of chronic low back pain and disability. PMR 1: 798-808.
- Lamb SE, Hansen Z, Lall R, Castelnuovo E, Nichols V (2010) Potter R, Underwood MR. Group cognitive behavioural treatment for low-back pain in primary care: a randomised controlled trial and cost-effectiveness analysis. Lancet 375: 916-923.
- NICE Low Back Pain – Early Management of Persistent Non-specific Low Back Pain.
- Van Geen J, Edelaar M, Janssen M, van Eijk J (2007) The long term effect of multidisciplinary back training: a systematic review. Spine 32: 249-255.
- Richards MC, Ford JJ, Slater SL, Hahne AJ, Surkitt LD, et al. (2013) The effectiveness of physiotherapy functional restoration for post-acute low back pain: a systematic review. Man Ther 18: 4-25.
- Fairbank J, Frost H, Wilson-MacDonald J, Yu LM, Barker K, et al. (2005) Randomised controlled trial of compare surgical stabilisation of the lumbar spine with an intensive rehabilitation programme for patients with chronic low back pain. BMJ 330: 1233.
- Mannion AF, Brox JI, Fairbank JCT (2013) Comparison of spinal fusion and non operative treatment in patients with chronic low back pain: long term follow-up of three randomized controlled trials. Spine J 13: 1438-1448.
- Dagenais S, Tricco AC, Haldeman S (2010) Synthesis of recommendations for the assessment and management of low back pain from recent clinical practice guidelines. Spine J 10: 514-529.
- Airaksinen O, Brox JL, Cedraschi C, Hildebrandt J, Klaber-Moffett J, et al. (2006) Chapter 4 European guidelines for the management of chronic low back pain in primary care. Eur Spine J 15: 5192-5300.
- Chou R, Qaseem A, Snow V, Casey D, Cross JT jr, et al. (2007) Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med 147: 478-491.
- Smeets RJEM, Vlaeyen JWS, Hidding A, Kester ADM, van der Heijden GJMG, et al. (2006) Active rehabilitation for chronic low back pain: Cognitive-behavioral, physical or both? First direct post-treatment results from a randomized controlled trial. BMC Musculoskelet Disord 7: 5.
- Van Middelkoop M, Rubinstein SM, Kuijpers T, Verhagen AP, Ostelo R, et al. (2011) A systematic review on the effectiveness of physical and rehabilitation interventions for chronic non-specific low back pain. Eur Spine J 20: 19-39.
- Zigmund AS, Snaith RP (1983) The Hospital Anxiety and Depression Scale. Acta Psychiatra Scand 67: 361-370.
- Fairbank J, Pynsent P (2000) The Oswestry Disability Index. Spine 25: 2940-2953.
- Jensen MP, Karoly P, Braver S (1986) The measurement of clinical pain intensity: a comparison of six methods. Pain 27: 117-126.
- Miller RP, Kori S, Todd D (1991) The Tampa Scale: a measure of kinesiophobia. Clin J Pain 7: 51–52.
- Sullivan MJL, Bishop SC, Pivik J (1995) The Pain Catastrophizing Scale: Development and validation. Psychological Assessment 7: 524-532.
- Chapman JR, Norveu DC, Hermsmeyer JT, Bransford BJ, Devine J, et al. (2011) Evaluating common outcomes for measuring treatment success for chronic low back pain. Spine 36: S54-68.
- Nicholas MK (2007) The pain self-efficacy questionnaire: Taking pain into account. Eur J Pain 11: 153-163.
- Miles CL, Pincus T, Carnes D, Taylor SJC, Underwood M (2011) Measuring pain self efficacy. Clin J Pain 27: 461-470.
- Durlak JA (2009) How to select, calculate and interpret effect sizes. J Pediatr Psychol 34: 917-928.
- Guzman J, Esmail R, Karjalainen K, Malmivaara A, Irwin E, et al. (2001) Multidisciplinary rehabilitation for chronic low back pain: systematic review. BMJ 322: 1511-1516.
- Flor H, Fydrich T, Turk DC (1992) Efficacy of multidisciplinary pain treatment centers: a meta-analytic review. Pain 49: 221-230.
- Waterschoot FPC, Dijkstra PU, Hollak N, de Vries HJ, Geertzen JHB (2014) Dose or content? Effectiveness of pain rehabilitation programs for patients with chronic low back pain: A systematic review. Pain 155: 179-189.
- Williams AC (2014) How do we understand dose of rehabilitative treatment? Pain 155: 8-9.
- Gatchel RJ, Mayer TG (2008) Evidence informed management of chronic low back pain with functional restoration. Spine J 8: 65-69.
- Dopson S, Fitzgerald L, Ferlie E, Gabbay J, Locock L (2002) No magic targets! Changing clinical practice to become more evidence based. Health Care Manage Rev 27: 35-47.
- Moore AP, Jull G (2012) Research culture development in the workplace – the key to professional success. Man Ther 17: 487-488.
- Rycroft-Malone J, Wilkinson JE, Burton CR, Andrews G, Ariss S, et al. (2011) Implementing health research through academic and clinical partnerships: a realistic evaluation of the Collaborations for Leadership in Applied Health Research and Care (CLAHRC). Implement Sci 6: 74.