Behavioral Graded Activity Research Articles

2 Mini Oral - The effect of pain neuroscience education and behavioural graded activity in breast cancer survivors: a randomised controlled multi-center trial

2 Mini Oral - The effect of pain neuroscience education and behavioural graded activity in breast cancer survivors: a randomised controlled multi-center trial

Exercise therapy for knee osteoarthritis pain: how does it work? A study protocol for a randomised controlled trial

IntroductionMuscle strengthening training (MST) and behavioural graded activity (BGA) show comparable effects on knee osteoarthritic (KOA) pain, but the mechanisms of action remain unclear. Both exercise-induced anti-inflammation and central sensitisation...

The effect of psychologically informed practice with behavioural graded activity in cancer survivors: systematic review and meta-analysis.

This systematic review and meta-analysis aimed to determine the effectiveness of psychologically informed practice (PIP) with behavioural graded activity (BGA) compared to (1) waitlist controls (WLC), (2) other interventions (OI), (3) PIP alone or (4) BGA alone in cancer patients and survivors (CPaS). PubMed, Web of Science and Embase were screened for randomised controlled trials encompassing BGA + PIP in CPaS. Effect sizes were inventoried for outcomes regarding physical activity (PA), quality of life (QoL) and debilitating symptoms (DS), which were assessed at four time points: post-intervention (PI), follow-up F1 (1 to 3months), F2 (4 to 6months) and F3 (> 6months). The quality of the evidence was classified by the GRADE approach. Thirty-three studies were found eligible, comprising 4330 participants. Significant effects with low heterogeneity of PIP + BGA comparing to WLC were found for anxiety (SMD - 1.29 [-1.71; - 0.86]), depression (SMD - 0.79 [- 1.10; - 0.48]), functional impairment (SMD - 0.72 [- 0.95; - 0.50]), PA (self-reported: (SMD - 0.58 [- 0.84; - 0.32]) and objectively measured: (SMD - 0.51 [- 0.90; - 0.13])) and social impairment (SMD - 0.33 [- 0.58; - 0.08]). When comparing PIP + BGA to OI, fatigue (SMD - 0.35 [- 0.51; - 0.20]) and PA (SMD - 0.26 [- 0.41; - 0.11]) at PI, and fatigue (SMD - 0.34 [- 0.58; - 0.10]) at F1 were found significant with low heterogeneity. No significant effects were observed in the meta-analyses of studies comparing PIP + BGA to BGA or PIP alone. PIP with BGA has a favourable effect on DS, PA and QoL in CPaS when compared to non-behavioural interventions such as WLC, usual care and education. However, further research is needed on 'how' and 'when' PIP + BGA should be provided in cancer rehabilitation. PIP + BGA has the potential to facilitate CPaS to reach the recommended amount of PA and reduce DS.

23 (PB-023) Poster Spotlight - The effect of behavioral graded activity on physical activity level, health-related quality of life, and symptom management in cancer patients and survivors: systematic review and meta-analysis

Background: In past years, behavioral graded activity (BGA) has demonstrated positive effects on debilitating symptoms, physical functioning, and pain in chronic pain populations, and appears foremost in cognitive behavioral therapy or other psychological informed practices (PIP). Up to now, no systematic review has been published about the effect of BGA on different biopsychosocial outcomes within cancer populations. Therefore, this systematic review and meta-analysis determined the effectiveness of PIP with BGA compared to (1) waitlists (WL), (2) usual care (UC), (3) PIP alone, or (4) BGA alone in cancer patients and survivors (CPaS).

Rehabilitation after lumbar disc surgery

Several rehabilitation programmes are available for individuals after lumbar disc surgery. To determine whether active rehabilitation after lumbar disc surgery is more effective than no treatment, and to describe which type of active rehabilitation is most effective. This is the second update of a Cochrane Review first published in 2002.First, we clustered treatments according to the start of treatment.1. Active rehabilitation that starts immediately postsurgery.2. Active rehabilitation that starts four to six weeks postsurgery.3. Active rehabilitation that starts longer than 12 months postsurgery.For every cluster, the following comparisons were investigated.A. Active rehabilitation versus no treatment, placebo or waiting list control.B. Active rehabilitation versus other kinds of active rehabilitation.C. Specific intervention in addition to active rehabilitation versus active rehabilitation alone. We searched CENTRAL (2013, Issue 4) and MEDLINE, EMBASE, CINAHL, PEDro and PsycINFO to May 2013. We included only randomised controlled trials (RCTs). Pairs of review authors independently assessed studies for eligibility and risk of bias. Meta-analyses were performed if studies were clinically homogeneous. The GRADE approach was used to determine the overall quality of evidence. In this update, we identified eight new studies, thereby including a total of 22 trials (2503 participants), 10 of which had a low risk of bias. Most rehabilitation programmes were assessed in only one study. Both men and women were included, and overall mean age was 41.4 years. All participants had received standard discectomy, microdiscectomy and in one study standard laminectomy and (micro)discectomy. Mean duration of the rehabilitation intervention was 12 weeks; eight studies assessed six to eight-week exercise programmes, and eight studies assessed 12 to 13-week exercise programmes. Programmes were provided in primary and secondary care facilities and were started immediately after surgery (n = 4) or four to six weeks (n = 16) or one year after surgery (n = 2). In general, the overall quality of the evidence is low to very low. Rehabilitation programmes that started immediately after surgery were not more effective than their control interventions, which included exercise. Low- to very low-quality evidence suggests that there were no differences between specific rehabilitation programmes (multidisciplinary care, behavioural graded activity, strength and stretching) that started four to six weeks postsurgery and their comparators, which included some form of exercise. Low-quality evidence shows that physiotherapy from four to six weeks postsurgery onward led to better function than no treatment or education only, and that multidisciplinary rehabilitation co-ordinated by medical advisors led to faster return to work than usual care. Statistical pooling was performed only for three comparisons in which the rehabilitation programmes started four to six weeks postsurgery: exercise programmes versus no treatment, high- versus low-intensity exercise programmes and supervised versus home exercise programmes. Very low-quality evidence (five RCTs, N = 272) shows that exercises are more effective than no treatment for pain at short-term follow-up (standard mean difference (SMD) -0.90; 95% confidence interval (CI) -1.55 to -0.24), and low-quality evidence (four RCTs, N = 252) suggests that exercises are more effective for functional status on short-term follow-up (SMD -0.67; 95% CI -1.22 to -0.12) and that no difference in functional status was noted on long-term follow-up (three RCTs, N = 226; SMD -0.22; 95% CI -0.49 to 0.04). None of these studies reported that exercise increased the reoperation rate. Very low-quality evidence (two RCTs, N = 103) shows that high-intensity exercise programmes are more effective than low-intensity exercise programmes for pain in the short term (weighted mean difference (WMD) -10.67; 95% CI -17.04 to -4.30), and low-quality evidence (two RCTs, N = 103) shows that they are more effective for functional status in the short term (SMD -0.77; 95% CI -1.17 to -0.36). Very low-quality evidence (four RCTs, N = 154) suggests no significant differences between supervised and home exercise programmes for short-term pain relief (SMD -0.76; 95% CI -2.04 to 0.53) or functional status (four RCTs, N = 154; SMD -0.36; 95% CI -0.88 to 0.15). Considerable variation was noted in the content, duration and intensity of the rehabilitation programmes included in this review, and for none of them was high- or moderate-quality evidence identified. Exercise programmes starting four to six weeks postsurgery seem to lead to a faster decrease in pain and disability than no treatment, with small to medium effect sizes, and high-intensity exercise programmes seem to lead to a slightly faster decrease in pain and disability than is seen with low-intensity programmes, but the overall quality of the evidence is only low to very low. No significant differences were noted between supervised and home exercise programmes for pain relief, disability or global perceived effect. None of the trials reported an increase in reoperation rate after first-time lumbar surgery. High-quality randomised controlled trials are strongly needed.

Effectiveness of a Web-Based Physical Activity Intervention in Patients With Knee and/or Hip Osteoarthritis: Randomized Controlled Trial

BackgroundPatients with knee and/or hip osteoarthritis (OA) are less physically active than the general population, while the benefits of physical activity (PA) have been well documented. Based on the behavioral graded activity treatment, we developed a Web-based intervention to improve PA levels in patients with knee and/or hip OA, entitled “Join2move”. The Join2move intervention is a self-paced 9-week PA program in which the patient’s favorite recreational activity is gradually increased in a time-contingent way.ObjectiveThe aim of the study was to investigate whether a fully automated Web-based PA intervention in patients with knee and/or hip OA would result in improved levels of PA, physical function, and self-perceived effect compared with a waiting list control group.MethodsThe study design was a two-armed randomized controlled trial which was not blinded. Volunteers were recruited via articles in newspapers and health-related websites. Eligibility criteria for participants were: (1) aged 50-75 years, (2) self-reported knee and/or hip OA, (3) self-reported inactivity (30 minutes of moderate PA, 5 times or less per week), (4) no face-to-face consultation with a health care provider other than general practitioners, for OA in the last 6 months, (5) ability to access the Internet weekly, and (6) no contra-indications to exercise without supervision. Baseline, 3-month, and 12-month follow-up data were collected through online questionnaires. Primary outcomes were PA, physical function, and self-perceived effect. In a subgroup of participants, PA was measured objectively using accelerometers. Secondary outcomes were pain, fatigue, anxiety, depression, symptoms, quality of life, self-efficacy, pain coping, and locus of control.ResultsOf the 581 interested respondents, 199 eligible participants were randomly assigned to the intervention (n=100) or waiting list control group (n=99). Response rates of questionnaires were 84.4% (168/199) after 3 months and 75.4% (150/199) after 12 months. In this study, 94.0% (94/100) of participants actually started the program, and 46.0% (46/100) reached the adherence threshold of 6 out of 9 modules completed. At 3 months, participants in the intervention group reported a significantly improved physical function status (difference=6.5 points, 95% CI 1.8-11.2) and a positive self-perceived effect (OR 10.7, 95% CI 4.3-26.4) compared with the control group. No effect was found for self-reported PA. After 12 months, the intervention group showed higher levels of subjective (difference=21.2 points, 95% CI 3.6-38.9) and objective PA (difference=24 minutes, 95% CI 0.5-46.8) compared with the control group. After 12 months, no effect was found for physical function (difference=5 points, 95% CI −1.0 to 11.0) and self-perceived effect (OR 1.2, 95% CI 0.6-2.4). For several secondary endpoints, the intervention group demonstrated improvements in favor of the intervention group.ConclusionsJoin2move resulted in changes in the desired direction for several primary and secondary outcomes. Given the benefits and its self-help format, Join2move could be a component in the effort to enhance PA in sedentary patients with knee and/or hip OA.Trial RegistrationThe Netherlands National Trial Register: NTR2483; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=2483 (Archived by WebCite at http://www.webcitation.org/67NqS6Beq).

Cost-effectiveness of conservative treatments for neck pain: a systematic review on economic evaluations

PurposeVarious conservative interventions have been used for the treatment of non-specific neck pain. The aim of this systematic review was to investigate the cost-effectiveness of conservative treatments for non-specific neck pain.MethodsClinical and economic electronic databases, reference lists and authors’ databases were searched up to 13 January 2011. Two reviewers independently selected studies for inclusion, performed the risk of bias assessment and data extraction.ResultsA total of five economic evaluations met the inclusion criteria. All studies were conducted alongside randomised controlled trials and included a cost-utility analysis, and four studies also conducted a cost-effectiveness analysis. Most often, the economic evaluation was conducted from a societal or a health-care perspective. One study found that manual therapy was dominant over physiotherapy and general practitioner care, whilst behavioural graded activity was not cost-effective compared to manual therapy. The combination of advice and exercise with manual therapy was not cost-effective compared to advice and exercise only. One study found that acupuncture was cost-effective compared to a delayed acupuncture intervention, and another study found no differences on cost-effectiveness between a brief physiotherapy intervention compared to usual physiotherapy. Pooling of the data was not possible as heterogeneity existed between the studies on participants, interventions, controls, outcomes, follow-up duration and context related socio-political differences.ConclusionAt present, the limited number of studies and the heterogeneity between studies warrant no definite conclusions on the cost-effectiveness of conservative treatments for non-specific neck pain.

Is Behavioral Graded Activity Cost-Effective in Comparison With Manual Therapy for Patients With Subacute Neck Pain?

An economic evaluation alongside a randomized controlled trial comparing behavioral graded activity (BGA) with manual therapy (MT). To evaluate the cost-effectiveness of BGA in comparison with MT for patients with subacute neck pain from a societal perspective. Neck pain is common and poses an important socioeconomic burden to society. Data on the cost-effectiveness of treatments for neck pain are scarce. A randomized clinical trial was conducted, involving 146 patients with subacute nonspecific neck pain. The BGA program can be described as a time-contingent increase in activities from baseline toward predetermined goals. MT consists of specific spinal mobilization techniques and exercises. Clinical outcomes included recovery, pain, disability, and quality-adjusted life-years (QALYs). Costs were measured from a societal perspective using cost diaries. The follow-up period was 52 weeks. Multiple imputation was used for missing cost and effect data. Uncertainty surrounding cost differences and incremental cost-effectiveness ratios was estimated using bootstrapping. Cost-effectiveness planes and cost-effectiveness acceptability (CEA) curves were estimated. BGA had no significant effect on recovery or QALYs gained in comparison with MT but pain and disability did improve significantly in the BGA group in comparison with the MT group. Total societal costs in the BGA group were nonsignificantly higher than in the MT group. Cost-effectiveness analyses showed that BGA is not cost-effective in comparison with MT for recovery and QALYs gained. Substantial investments are needed to reach a 0.95 probability that BGA is cost-effective in comparison with MT for pain and disability. On the basis of the data presented, we consider BGA not cost-effective in comparison with MT.

Long-term effectiveness of exercise therapy in patients with osteoarthritis of the hip or knee: a randomized controlled trial comparing two different physical therapy interventions

To determine if behavioral graded activity (BGA) results in better long-term effectiveness (5 years after inclusion) than usual exercise therapy (UC; usual care) in patients with osteoarthritis (OA) of the hip or knee. Long-term follow-up study of a single blind cluster randomized trial comparing BGA and UC. One hundred and forty-nine patients out of the 200 included were followed until 60 months' follow-up. Primary outcome measures were pain, physical function, and patient global assessment. Furthermore, patient-oriented physical function, physical performance, health care utilization and the number of joint replacement surgeries were assessed. Assessments took place at 3, 9, 15 and 60 months' follow-up. Data were analyzed according to intent-to-treat principle. Both treatments showed beneficial within-groups effects in the long-term. In patients with knee OA no differences between treatments were found on the short-, mid-long and long-term. In patients with hip OA significant differences in favor of BGA were found at 3 months' (pain and physical performance) and 9 months' follow-up (pain, physical function, patients global assessment and patient-oriented physical function). Furthermore, UC resulted in patients with hip OA in more joint replacement surgeries compared to BGA (hazard ratio [HR], 2.87; 95% confidence interval [CI], 1.1; 7.3). No differences between treatment groups were found in the long-term on the primary outcome measures. Although more research is needed to confirm the study findings, the results indicate that BGA reduces the risk for joint replacement surgeries compared to UC in patients with hip OA, which probably can be explained by better outcome in favor of BGA in the short- and mid-long-term.

Is a Behavioral Graded Activity Program More Effective Than Manual Therapy in Patients With Subacute Neck Pain?

A randomized clinical trial. To compare the effectiveness of a behavioral graded activity program with manual therapy in patients with subacute (4-12 weeks) nonspecific neck pain. Neck pain is a common complaint, for which many conservative therapies are available in primary care. There is strong evidence for manual therapy in combination with exercises. Psychosocial factors are also believed to play a role in chronic pain. The evidence of the effectiveness of a program focused on these factors is still unknown. A randomized clinical trial was conducted, involving 146 patients with subacute nonspecific neck pain. The BGA program can be described as a time-contingent increase in activities from baseline toward predetermined goals. Manual therapy consists of specific spinal mobilization techniques and exercises. Primary outcomes were global perceived effect, the Numerical Rating Scale for pain and the Neck Disability Index. Secondary outcomes were the Tampa Scale for Kinesiophobia, the 4 Dimensional Symptom Questionnaire, and the Pain Coping and Cognition List. Measurements were carried out at baseline and 6, 13, 26, and 52 weeks after randomization. Data are analyzed according to the intention-to-treat principle, using multilevel analysis. The success rates at 52 weeks, based on the GPE were 89.4% for the BGA program and 86.5% for MT. This difference was not statistically significant. For pain and disability, a difference was found in favor of the BGA program; mean difference for pain = 0.99 (95% CI 0.15-1.83) and mean difference for NDI = 2.42 (95% CI 0.52-4.32). All other differences between the interventions in the primary and secondary outcomes were not statistically significant. Based on this trial it can be concluded that there are only marginal, but not clinically relevant, differences between a BGA program and MT.

Behavioural graded activity results in better exercise adherence and more physical activity than usual care in people with osteoarthritis: a cluster-randomised trial

Does behavioural graded activity result in better exercise adherence and more physical activity than usual care in people with osteoarthritis of the hip or knee? Analysis of secondary outcomes of a cluster-randomised trial with concealed allocation, assessor blinding, and intention-to-treat analysis. Two hundred patients with hip and/or knee osteoarthritis. Experimental group received 18 sessions of behavioural graded activity over 12 weeks and up to 7 booster sessions over the next year. The control group received 18 sessions of usual care over 12 weeks according to the Dutch physiotherapy guideline. Exercise adherence was measured using a questionnaire and physical activity was measured using the SQUASH questionnaire at baseline, 13, and 65 weeks. Adherence to recommended exercises was significantly higher in the experimental group than in the control group at 13 weeks (OR 4.3, 95% CI 2.1 to 9.0) and at 65 weeks (OR 3.0, 95% CI 1.5 to 6.0). Significantly more of the experimental than the control group met the recommendations for physical activity at 13 weeks (OR 5.3, 95% CI 1.9 to 14.8) and at 65 weeks (OR 2.9, 95% CI 1.2 to 6.7). Behavioural graded activity results in better exercise adherence and more physical activity than usual care in people with osteoarthritis of the hip or knee, both in the short- and long-term. NCT00522106.

Physiotherapists' treatment approach towards neck pain and the influence of a behavioural graded activity training: An exploratory study

Physiotherapists' treatment approach might influence their behaviour during practice and, consequently, patients' treatment outcome; however, an explicit description of the treatment approach is often missing in trials. The purpose of this prospective exploratory study was to evaluate whether the treatment approach differs between therapists who favour a behavioural graded activity (BGA) program, conservative exercise (CE) or manual therapy, and whether BGA training has influence on the treatment approach. Forty-two therapists participated. BGA therapists received a 2-day training. Treatment approach was measured at baseline and at 3-month follow-up, using the Pain Attitude and Beliefs Scale for Physiotherapists (PABS-PTs). By this method data on the adoption of biomedical or biopsychosocial approaches were generated. Differences were examined with analysis of variance (ANOVA) and independent Student's t-test. Influence of the BGA training was examined with linear regression. At baseline, there were no significant differences between BGA, CE or manual therapists use of biomedical or biopsychosocial approaches, but there was a trend for BGA therapists to score higher on the biopsychosocial approach. At follow-up, their biopsychosocial score remained higher and their biomedical score was lower compared to CE therapists. Corrected regression analysis showed a 4.4 points (95%CI −7.9; −0.8) higher decrease for therapists who followed the BGA training compared to therapists who did not. Our results indicate no significant differences in treatment approach at baseline, and that BGA training might influence therapists' treatment approach since the scores on the biomedical approach decreased.

Which patientswith osteoarthritis of hip and/or knee benefit most from behavioral graded activity?

Our objective was to investigate whether behavioral graded activity (BGA) has particular benefit in specific subgroups of osteoarthritis (OA) patients. Two hundred participants with OA of hip or knee, or both (clinical American College of Rheumatology, ACR, criteria) participated in a randomized clinical trial on the efficacy of BGA compared to treatment according to the Dutch physiotherapy guideline (usual care; UC). Changes in pain (Visual Analog Scale, VAS), physical functioning (Western Ontario and McMaster Universities Osteoarthritis Index, WOMAC, and McMaster Toronto Arthritis Questionnaire, MACTAR), and patient global assessment were compared for specific subgroups. Subgroups were assigned by the median split method and were analyzed using analysis of covariance. Beneficial effects of BGA were found for patients with a relatively low level of physical functioning (p?0.03). Furthermore, beneficial effects of BGA in patients with a low level of internal locus of control were marginally significant (p = .05). Patients with a relatively low level of physical functioning benefit more from BGA compared to UC. Compared to UC, BGA is the preferred treatment option in patients with a low level of physical functioning.

Is behavioral graded activity effective for the treatment of hip and knee osteoarthritis?

Is behavioral graded activity effective for the treatment of hip and knee osteoarthritis?

Effectiveness of behavioral graded activity in patients with osteoarthritis of the hip and/or knee: A randomized clinical trial

To determine the effectiveness of a behavioral graded activity program (BGA) compared with usual care (UC; exercise therapy and advice) according to the Dutch guidelines for physiotherapy in patients with osteoarthritis (OA) of the hip and/or knee. The BGA intervention is intended to increase activity in the long term and consists of an exercise program with booster sessions, using operant treatment principles. We conducted a cluster randomized trial involving 200 patients with hip and/or knee OA. Primary outcome measures were pain (visual analog scale [VAS] and Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC]), physical function (WOMAC), and patient global assessment, assessed at weeks 0, 13, 39, and 65. Secondary outcome measures comprised tiredness (VAS), patient-oriented physical function (McMaster Toronto Arthritis Patient Preference Disability Questionnaire [MACTAR]), 5-meter walking time, muscle strength, and range of motion. Data were analyzed according to intent-to-treat principle. Both treatments showed short-term and long-term beneficial within-group effects. The mean differences between the 2 groups for pain and functional status were not statistically significant. Significant differences in favor of BGA were found for the MACTAR functional scale and 5-meter walking test at week 65. Because both interventions resulted in beneficial long-term effects, the superiority of BGA over UC has not been demonstrated. Therefore, BGA seems to be an acceptable method to treat patients with hip and/or knee OA, with equivalent results compared with UC.

Active involvement and long-term goals influence long-term adherence to behavioural graded activity in patients with osteoarthritis: a qualitative study

Why do some patients who have received a behavioural graded activity program successfully integrate the activities into their daily lives and others do not? Qualitative study. 12 patients were selected according to the model of deliberate sampling for heterogeneity, based on their success with the intervention as assessed on the Patient Global Assessment. Behavioural graded activity. Data from 12 interviews were coded and analysed using the methods developed in grounded theory. The interviews covered three main themes: aspects related to the content of behavioural graded activity, aspects related to experience with the physiotherapist, and aspects related to characteristics of the participant. Interview responses suggest that two factors influence long-term adherence to exercise and activity.First, initial long-term goals rather than short-term goals seem to relate to greater adherence to performing activities in the long term. Second, active involvement by participants in the intervention process seems to relate to greater adherence to performing activities in the long term. Although involvement of patients in the intervention process is already part of behavioural graded activity, it would be beneficial to emphasise the importance of active involvement by patients right from the start of the intervention. Furthermore, to increase the success of behavioural graded activity, physiotherapists should gain a clear understanding of the patient's initial motives in undergoing intervention.

Comparison of the effectiveness of a behavioural graded activity program and manual therapy in patients with sub-acute neck pain: Design of a randomized clinical trial

The objective is to present the design of a randomized clinical trial (RCT) on the effectiveness and cost effectiveness of a behavioural graded activity programme compared with manual therapy in patients with sub-acute neck pain. Sub-acute is defined as pain existing for 4–12 weeks. The behavioural graded activity programme is a time-contingent increase in activities from baseline towards pre-determined goals. Manual therapy consists mainly of specific spinal mobilization techniques and exercises. The primary outcomes are global perceived effect and functional status. Secondary outcomes are kinesiophobia, distress, coping, depression and somatization. The intensity and persistence of the pain and its interference with activities are also assessed. Direct and indirect costs are measured by means of cost diaries. Measurements take place at baseline and 6 and 12 weeks after randomization. To assess the long-term effect, measurements will also take place after 6 and 12 months. Finally some challenges are discussed concerning the use of a behavioural graded activity programme, manual therapy and outcomes.

Behavioral Graded Activity Following First-Time Lumbar Disc Surgery

In a randomized clinical trial, the effectiveness of behavioral graded activity was assessed as compared to usual care provided by physiotherapists for patients after first-time lumbar disc surgery (n = 105). Little is known about the effectiveness of rehabilitation programs following lumbar disc surgery. Most programs focus on biomechanical aspects, whereas psychosocial factors are hardly addressed. The aim of the behavioral graded activity program, which is an operant treatment, is to alter psycho-social factors such as fear of movement and pain catastrophizing, which might subsequently lead to improved functional status and higher rates of recovery. Behavioral treatments for patients following lumbar disc surgery have not yet been assessed in a randomized clinical trial. age between 18 and 65 years; first-time lumbar disc surgery; restrictions in normal activities of daily living. surgical complications and confirmed and relevant underlying diseases. Outcome assessment took place at 6 and 12 months after randomization. Six months after randomization, 62% of the patients had recovered following usual care versus 65% of the patients following behavioral graded activity. After 12 months, 73% and 75%, respectively, had recovered. Differences between intervention groups, 3% and 2% respectively, after 6 and 12 months are not statistically significant. Furthermore, there were no differences between the two groups regarding functional status, pain, pain catastrophizing, fear of movement, range of motion, general health, social functioning or return to work. After 1 year, 4 of the behavioral graded activity cases had undergone another operation versus 2 of usual care cases. Both fear of movement and pain catastrophizing seem to be unaffected by either treatment in these patients. It is concluded that treatment principles derived from theories within the field of chronic low back pain might not apply to these patients. After 1 year of follow-up, there were no statistically significant or clinically relevant differences between the behavioral graded activity program and usual care as provided by physiotherapists for patients following first-time lumbar disc surgery.

Behavioral-graded activity compared with usual care after first-time disk surgery: Considerations of the design of a randomized clinical trial

Objective: To present the design of a trial on the effectiveness of a behavioral-graded activity model.Design: Randomized clinical trial.Patients: Patients undergoing first-time lumbar disk surgery who still have low-back pain at the 6-week neurosurgical consultation.Interventions: A patient-tailored behavioral-graded activity program that is based on operant therapy. The key elements of this program are baseline measurements, goal-setting, and time-contingency. This program is compared with usual care in physiotherapy, which is pain-contingent.Outcome Measures: Primary measures are the patient's global impression of the effect and their functional status. Secondary measures are kinesiophobia, catastrophizing, pain, main complaint, range of motion, and relapses. The direct and indirect costs will also be assessed. The effect measures are rated before randomization and 3, 6, and 12 months later.Discussion: Several trials have been conducted on the effectiveness of behavioral treatments. Subjects were always patients with chronic low-back pain. In this trial, we apply such a treatment in patients after first-time disk surgery in a primary care setting.

Behavioral-graded activity compared with usual care after first-time disk surgery: Considerations of the design of a randomized clinical trial*1

Behavioral-graded activity compared with usual care after first-time disk surgery: Considerations of the design of a randomized clinical trial*1