A short, intensive cognitive behavioral pain management program reduces health-care use in patients with chronic low back pain: two-year follow-up results of a prospective cohort.

Abstract

Cognitive behavioral interventions are recommended as non-invasive treatment options for patients with chronic low back pain (CLBP). However, most treatment effects are small and short-lived. Although a 2-week intensive pain management program for patients with CLBP seems to be effective, the long-term results are not known. The purpose of this study is to evaluate the stability of the 2-year follow-up results and whether this is reflected in the use of health-care services.
A prospective cohort study was performed. Pre-treatment characteristics of patients and data of outcomes obtained at 1-year follow-up were used. At 2-year follow-up a structured interview was conducted following the principles of a post-marketing survey. Outcomes included daily functioning, quality of life, current intensity of pain, disturbance of pain during daily activities, and indicators of the use of pain medication and health-care services.
Of the 90 eligible patients 85 (94%) participated in the post-marketing survey. The 1-year clinical relevant effects are maintained at 2-year follow-up. Effect sizes for functioning and quality of life were large. More than 65% reached preset minimal clinically important differences. At pre-treatment all patients consulted their general practitioner (GP) and medical specialist (MS). At 2-year follow-up 73% reported having consulted neither a GP nor an MS during the previous year. Most of the patients indicated not to use any pain medication (57%) and the percentage patients using opioids have decreased (14%). Moreover, 81% reported to be at work.
The gained results from selected and motivated patients with longstanding CLBP at 1-year follow-up are stable at 2-year follow-up. Above all, most of the participants are at work and results indicate that the use of both pain medication and health care have decreased substantially.

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ORIGINAL ARTICLE
A short, intensive cognitive behavioral pain management program
reduces health-care use in patients with chronic low back pain
Two-year follow-up results of a prospective cohort
Miranda L. van Hooff•Werner ter Avest•Philip P. Horsting•John O’Dowd•
Marinus de Kleuver•Wim van Lankveld•Jacques van Limbeek
Received: 22 April 2011/Revised: 29 September 2011/Accepted: 14 November 2011/Published online: 3 December 2011
? The Author(s) 2011. This article is published with open access at Springerlink.com
Abstract
Purpose
mended as non-invasive treatment options for patients with
chronic low back pain (CLBP). However, most treatment
effects are small and short-lived. Although a 2-week
intensive pain management program for patients with
CLBP seems to be effective, the long-term results are not
known. The purpose of this study is to evaluate the stability
of the 2-year follow-up results and whether this is reflected
in the use of health-care services.
Methods
A prospective cohort study was performed. Pre-
treatment characteristics of patients and data of outcomes
obtained at 1-year follow-up were used. At 2-year follow-
up a structured interview was conducted following the
principles of a post-marketing survey. Outcomes included
daily functioning, quality of life, current intensity of pain,
disturbance of pain during daily activities, and indicators of
the use of pain medication and health-care services.
Results
Of the 90 eligible patients 85 (94%) participated
in the post-marketing survey. The 1-year clinical relevant
effects are maintained at 2-year follow-up. Effect sizes for
functioning and quality of life were large. More than 65%
Cognitive behavioral interventions are recom-
reached preset minimal clinically important differences. At
pre-treatment all patients consulted their general practi-
tioner (GP) and medical specialist (MS). At 2-year follow-
up 73% reported having consulted neither a GP nor an MS
during the previous year. Most of the patients indicated not
to use any pain medication (57%) and the percentage
patients using opioids have decreased (14%). Moreover,
81% reported to be at work.
Conclusions
The gained results from selected and moti-
vated patients with longstanding CLBP at 1-year follow-up
are stable at 2-year follow-up. Above all, most of the
participants are at work and results indicate that the use of
both pain medication and health care have decreased
substantially.
Keywords
Cognitive behavioral program ? Pain management ?
Daily functioning
Chronic low back pain ? Health-care services ?
Introduction
Low back pain is one of the most common disabling
conditions and causes high health expenditure in developed
countries [1–3]. This condition has a high prevalence: over
70% of the adult population experience at least one episode
of low back pain [1, 4–6]. In the Netherlands the annual
prevalence in 2003 was approximately 44% [1]. A minority
(20%) develop chronic low back pain (CLBP), meaning
that the complaints persist at least 3 months [2] and are
associated with persistent or recurrent disability. These
complaints may result in the individuals experiencing a
lower health-related quality of life; they cause a quarter of
all sick leave in the employed population [1, 3, 4]. The
Dutch National Institute for Public Health and the
M. L. van Hooff (&) ? W. ter Avest ? W. van Lankveld ?
J. van Limbeek
Department Research Development and Education,
Sint Maartenskliniek, P.O. Box 9011,
6500 GM Nijmegen, The Netherlands
e-mail: m.vanhooff@maartenskliniek.nl
P. P. Horsting ? M. de Kleuver
Department of Orthopedics, Sint Maartenskliniek,
P.O. Box 9011, 6500 GM Nijmegen, The Netherlands
J. O’Dowd
The RealHealth Institute, 23-31 Beavor Lane,
London W6 9AR, UK
123
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DOI 10.1007/s00586-011-2091-0

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Environment (RIVM) estimated CLBP-related costs to be
0.9% of total health-care costs in the Netherlands [5],
resulting in its being the top three of the highest health-care
costs [6]. Moreover, 14% of the adult population with a
disability allowance in the Netherlands is diagnosed with
CLBP. Therefore, CLBP is not only a burden for the
patient but the related health-care costs are also a problem
for society.
A wide range of interventions to manage CLBP are
used including pharmaceutical, surgical, and non-surgical
interventions [3, 7, 8]. However, many commonly used
interventions lack evidence of clinically relevant long-
term effects [4]. International guidelines [9–11], a
Cochrane review [12] as well as recently performed
randomized controlled trials have demonstrated that a
cognitive behavioral approach most effectively reduces
disability in CLBP patients [8, 13–15]. Nevertheless, most
effects achieved by these non-invasive treatments are
small and short-lived [14, 16–18]. A systematic review
with 1964 randomly allocated patients concluded that
100 h or more of intensive, multidisciplinary rehabilita-
tion with a functional restoration approach including
cognitive behavioral interventions reduces pain and
improves functionality [19]. Furthermore, most reported
treatment programs have a mean duration of 4 weeks [18,
20] or more [8, 13–15].
A recently published study by van Hooff et al. [21]
evaluated the 1 year results of a cohort of patients, who
participated in a 2-week program provided by RealHealth
NL. The program is based on cognitive behavioral princi-
ples and aims at improving daily functioning by self-
management of lower back pain complaints. Participants
with longstanding CLBP complaints (12 years on average)
learned to manage CLBP, improved fast in daily func-
tioning, and experienced a fast improvement in their
quality of life. These results were meaningful and clinically
relevant to the participants and comparable to results after
spinal surgery and superior to results for rehabilitation
programs of longer duration. However, the question
remains whether these positive short-term effects are sus-
tained in the long run and whether these benefits are
reflected in the degree of health-care use and the use of
pain medication.
Therefore, in this study the main purpose is to evaluate
the stability of the 2-year (long-term) follow-up results of a
short, intensive cognitive behavioral pain management
program provided by RealHealth NL. The emphasis is on
evaluating daily functioning, the use of health-care ser-
vices, and pain medication 2 years after the intervention.
We hope that improvements gained in the first year (short-
term) will be maintained and the use of health-care services
and pain medication will be reduced in the second year of
follow-up.
Materials and methods
Study design and setting
This study is an extension of a prospective cohort study in
which the effectiveness of an intensive cognitive behav-
ioral pain management program was evaluated after 1 year
of follow-up [21]. We used data obtained by questionnaire
at pre-treatment, including patient characteristics, outcome
measures and indicators of health care, and pain medica-
tion use. Outcome assessments performed at 1 year after
treatment yielded the primary outcome measure and heath-
related quality of life (Short-Form 36). These outcomes
were compared with outcome assessments at the 2-year
follow-up. To achieve a high response rate a structured
interview following the principles of a post-marketing
survey was added to obtain data at 2-year follow-up.
During this interview, the same questionnaires were used
as those completed at pre-treatment. A short description of
participants, treatment, and outcome measures follows.
Patients and treatment
A detailed description of participants and treatment has
been reported previously [21]. Patients entered the study
consecutively. The main inclusion criteria for the inter-
vention were low back pain for at least 6 months, no
indication for surgical or other invasive pain treatment
confirmed by spinal surgeons at the Sint Maartenskliniek,
no intention of seeking medical treatment in the year fol-
lowing the 2-week program, age between 20 and 65 years,
motivation to change behavior, willing to follow the pro-
gram and to reside in a hotel for 2 weeks, able to speak and
read Dutch. The main exclusion criterion was psychiatric
disorders.
The evidence-based, intensive cognitive behavioral pain
management program was developed by the RealHealth
Institute in the United Kingdom and follows published
international guidelines [9–11]. In the Netherlands all
sessions are delivered by the trainers of the RealHealth
multidisciplinary team. The team consists of a psycholo-
gist, a physiotherapist, and an occupational therapist. The
full program comprises an assessment day for intake, the
10 day residential program with two follow-up days:
1-month and 1-year post-treatment. The main aim of the
intervention is to improve daily functioning. This is
achieved by increasing the capability to self-manage the
CLBP complaints. The program consists of 100 h of par-
ticipant contact time, approximately 50 h of cognitive
behavioral training, 35 h of graded physical activities, and
15 h of education in which the cognitive behavioral prin-
ciples are integrated. The program is delivered in a 2-week,
group-orientated residential setting.
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Outcome assessment: procedure
Participants who had completed the 1-year follow-up were
contacted. All recruited respondents were telephoned by a
secretary and were asked if they were willing to participate
in a follow-up study, including a telephone survey at a later
time. When the respondent consented, the secretary made
the appointment for a telephone call; the questionnaire
booklet as well as a background information sheet was
sent. The participants completed the questionnaire at home
without assistance. The questionnaires are described in the
‘‘Outcome measures’’ section, which included daily func-
tioning, health-related quality of life, different pain scales,
and questions about use of health-care services, pain
medication, and return-to-work. An independent researcher
(W ter A) conducted the 20-min standardized telephone
interviews in the period March–June 2010. During the
telephone interview, the answers of the questionnaires were
passed without any discussion. A small gift voucher for
flowers as a present for participation was sent after the
interview was completed.
Outcome measures
Primary outcome
Roland and Morris Disability Questionnaire (RMDQ)
The RMDQ [22] contains 24 questions and measures
functional disability in patients with low back pain [8, 22].
The total score ranges between 0 (no disability) and 24
(maximal disability).
Secondary outcomes
Short-Form 36 Health Survey Questionnaire (SF36)
SF36 [23] is a generic instrument to measure the health-
related quality of life. The validated Dutch language
version has been used in a wide range of studies among
patients with chronic health conditions including CLBP
[24]. The instrument contains 36 items in 8 subscales. The
subscales results were combined into two summary scores:
the SF36 Physical Component Score (SF36 PCS) and the
SF36 Mental health Component Score (SF36 MCS).
The
Health-care use
consultation of a general practitioner (GP) or a medical
specialist (MS) and referral to a physical therapist (PT) or a
psychologist (PS) during the previous 12 months as well as
current pain medication consumption (analgesics). Patients
were asked to provide information before the program and
at 2-year follow-up. Consultation and referral questions
were scored on a dichotomous scale (yes/no), which in
addition to information about the frequency of these visits
Indicators for health-care use were
yielded an impression of the program’s impact on health-
care use. Pain medication was classified in accordance with
the three-step World Health Organization (WHO) analge-
sic ladder. These steps are (1) non-opioid analgesics with
adjuvant therapy when needed, (2) an addition of a weak
opioid, and (3) a strong opioid addition to non-opioid and
adjuvant therapy [25]. For this study, the first step was split
into two categories: (1A) paracetamol also known as
acetaminophen in the USA and (1B) non-steroidal anti-
inflammatory drugs (NSAIDs). Pain medication was then
classified as: ‘none-light’ (none and WHO-step 1A) and
‘moderate-severe’ (WHO-steps 1B-3). The ‘none/light’
classification indicates analgesics which have no or only
few side effects [3, 16, 26]. The analgesics in the ‘mod-
erate-severe’ classification are known to have adverse side
effects, especially when used for a long period [3]. Fur-
thermore, we classified consumption of analgesics as being
‘structural’ (daily) and ‘incidental’ (only when needed or
less than once a week).
Tertiary outcome
Visual analogue scales for pain to measure current inten-
sity and disturbance during daily activities (VAS ‘current
intensity’ and VAS ‘disturbance ADL’)
asked about the current intensity of their back pain for the
day of the questionnaire and about the disturbance of back
pain during daily activities. Both severity and disturbance
were marked on a line of 100 mm, with 0 mm indicating
‘no pain’ and 100 mm ‘unbearable pain’ [27, 28].
Participants were
Statistical analysis
Frequencies of characteristics assessed at pre-treatment and
health-care use are described. To compare the character-
istics of non-responders, an independent Student’s t test
was performed for the pre-treatment characteristics and the
outcome measures. Maintenance of gained results at 2-year
follow-up for all outcomes, except for health-care use, was
calculated with a paired samples Student’s t test.
To explore clinical relevance, we calculated effect sizes
(Cohens’ d) for primary and secondary outcomes (RMDQ
and SF36 PCS) to indicate the magnitude of treatment
effect for the RealHealth program. This measure is defined
as the difference between the means of the pre-treatment
assessment and of the 2-year follow-up divided by the
pooled standard deviation. An effect size (d) of 0.2 is
considered to be small, 0.5 moderate, while 0.8 indicates a
large effect [29]. Moreover, an effect size (d) of 1 is
equivalent to a change of 1 standard deviation in the study
sample.
All statistical analyses were conducted using SPSS,
version 17.0 for Windows. We set the level of significance
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at 0.05. Pie charts to present frequencies are created in
STATA version 10.0.
Results
Response
In March 2010, we had complete data sets available for 90
participants (84%), who were eligible to be contacted for
the 2-year follow-up. A total of five patients were seen as
non-responders, either because they could not be reached in
time (three patients) or was in final stage of illness and had
other priorities (one patient) or wished not to co-operate
(one patient). These five non-responders were not signifi-
cantly different to the included participants with regard to
pre-treatment characteristics
RMDQ, SF36, and both VAS scales (‘current intensity’ and
‘disturbance ADL’). A total of 85 participants (94%) joined
in the post-marketing survey at 2-year follow-up.
and outcomemeasures:
Patient characteristics
Table 1 shows the demographics of the 85 participants.
They reported longstanding CLBP (11 years on average)
and 29% had an earlier surgery for their back problem.
Clinical outcome
In Table 2 outcome measures are presented except those
for health-care use. Between 1- and 2-year follow-up
assessments the mean scores remained stable. Only pain
‘disturbance of ADL’ significantly improved between 1-
and 2-year follow-up: df (1, 84), t = 2.57, p = 0.01. In
Fig. 1 the trends, means with 95% confidence intervals for
the primary outcome ‘functional disability’ as measured
with the RMDQ, are graphically presented.
Health-care use
At the pre-treatment assessment all participants reported to
have consulted their general practitioner (GP) for their
back problem, at least once in the past year, and all of them
were referred to a medical specialist (MS; i.e., orthopedic
surgeon, neurologist, pain consultant, rheumatologist,
physiatrist, or anaesthesiologist). Furthermore, at pre-
treatment assessment 48% of the participants (n = 41) had
consulted at least two different MS in the previous year. At
2-year follow-up only a quarter of all participants, 27%
(n = 23) reported having consulted their GP in the last
year and 14 of these 23 consulted an MS just once. The
remaining 73% consulted neither a GP nor an MS in that
year.
At the pre-treatment assessment most of the participants
(94%; n = 80) indicated to have had physical therapy for
their back problem in the previous year. In addition, 15%
(n = 13) visited a psychologist. At 2-year follow-up the
allied health-care visits have considerably decreased, 29%
(n = 24) reported to have had physical therapy and only
1% (n = 1) consulted a psychologist for their back pain-
related problems in the last year.
Medication use decreased from 87% (n = 74) at base-
line to 43% (n = 37) at 2-year follow-up. At pre-treatment
assessment68%oftheparticipants (n = 58) used
Table 1 Pre-treatment demographics and 2-year follow-up results of return-to-work as reported by the participants (n = 85)
Demographics
n = 85
Sociodemographic
Age, mean (SD, range min–max) in years42.9 (±8.4, 23–60)
Gender n (%), male:female35 (41%):50 (59%)
Pre-treatment assessment2-year follow-up
Work status n (%)
Yes:no57 (68%):28 (32%)69 (81%):16 (19%)
At work—full time31 (37%)32 (38%)
At work—part time26 (31%)37 (44%)
Unemployed because of CLBP13 (15%)8 (9%)
Unemployed because of other causes4 (5%)3 (4%)
Disability pension11 (13%)5 (6%)
CLBP history
Duration of LBP, mean (SD, range min–max) in years12.2 (±11.3, 1–51)
Previous surgery n (%) yes:no25 (29%):60 (71%)
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analgesics for their back problem on a structural basis,
while 13% (n = 11) did not use any pain medication. The
pie charts in Fig. 2 show the frequencies of analgesic
consumption as classified in WHO analgesic ladder both at
pre-treatment and at 2-year follow-up. At 2-year follow-up
the ‘none-light’ consumption group has increased to
almost three quarters of the participants (n = 60; 71%),
while the ‘moderate-severe’ group has decreased to 29%
(n = 25).
Clinical relevance
The effect size (Cohens’ d) for functioning (RMDQ) is 1.6
and for functioning-related quality of life (SF36 PCS) is
1.4. The effect sizes of both measures were larger than 1
and, therefore, classified as ‘large’.
These results were further substantiated by data related
to work status as presented in Table 1. At 2-year follow-up,
81% of all participants reported being at work. Eight of the
13 participants who had reported at pre-treatment assess-
ment being unemployed because of their back problem
were working 2 years after the treatment. Moreover, 5 out
of 11 participants who received a disability allowance at
baseline indicated having returned to work.
Discussion
The main purpose of this study was to evaluate the 2-year
follow-up results of the cognitive behavioral pain man-
agement program offered by RealHealth NL in patients
with CLBP. We questioned whether improvements gained
in the first year would be maintained and whether this
would be reflected in the use of pain medication and health-
care services. Patients in our study population appeared to
have a mean baseline level of functioning as measured with
RMDQ (13 ± 4). This level is indicative for a moderate to
severe level of disability, which is comparable to patients
being treated in other trials and daily practice in the
Netherlands [8, 21]. In this study, we confirmed that the
previously reported 1-year clinically relevant effects on
daily functioning and quality of life were maintained at the
2-year follow-up. Participants even reported experiencing
less pain while performing activities; this decrease was
statistically significant. Moreover, health-care use (i.e., GP,
MS consultations and pain medication use at 2-year follow-
up) decreased between baseline and 2-year follow-up
assessment. Positive outcomes of the intervention were
further corroborated by work status data. Most of the par-
ticipants returned to work, with 81% actually working at
the 2-year follow-up. These results suggest that patients
who participated managed to incorporate the learned self-
Table 2 Mean (SD) for outcome measures at 1- and 2-year follow-up with t values for paired comparisons and significance levels (n = 85)
1-year FU2-year FU
t value
p value
Primary outcome
RMDQ7.5 (5.0)7.2 (5.0)0.750.45
Secondary outcomes
SF36 PCS64.6 (17.8)65.9 (20.6)-0.500.62
SF36 MCS70.9 (15.2)71.9 (17.1)-0.520.60
Tertiary outcomes
VAS ‘current intensity’35.9 (23.4)35.0 (27.5)0.960.34
VAS ‘disturbance in ADL’35.3 (26.9)27.1 (27.1)2.570.01*
FU follow-up, RMDQ Roland and Morris Disability Questionnaire, SF36 PCS Short Form 36 Physical Component Scale, SF36 MCS Short Form
36 Mental Component Scale, VAS visual analogue scale, with ‘current intensity’ indicating pain severity and ‘disturbance in ADL’ indicating
disturbance of pain during daily activities
* p\0.05
Roland & Morris Disability Questionnaire
0
2
4
6
8
10
12
14
16
18
Pre-treatment1-year follow up
Time
2-year follow up
RMDQ score ( 0 - 24 )
RMDQ
Fig. 1 Roland and Morris Disability Index (RMDQ); means and 95%
confidence intervals. Trend of maintenance of gained results between
1- and 2-year follow-up
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management techniques in daily life and that they changed
their occupational and social behavior.
Many commonly used interventions lack evidence for
the maintenance of clinically relevant long-term effects [4].
This study shows large effect sizes (Cohens’ d = 1.4–1.6).
Although we had five non-responders in the current study,
they did not differ in patient characteristics and outcomes
at baseline to the included patients. Their drop out was not
related to either the treatment program or the study itself.
Therefore, it is noteworthy that patients with longstanding
CLBP complaints, 11 years on average, benefit from this
short and intensive pain management program which is
based on international guidelines [9–11]. Post hoc analyses
revealed that no significant correlations existed between
duration of CLBP and change in outcome measures at
1-year follow-up (RMDQ r = 0.05; SF36PCS r = 0.07;
current pain r = 0.13; pain disturbance ADL r = 0.09) and
at 2-year follow-up (RMDQ r = 0.02; SF36PCS r = 0.08;
current pain r = 0.15; pain disturbance ADL r = 0.09).
The current study results suggest that the duration of CLBP
is not an important factor for the management of CLBP,
whereas duration and intensiveness of the program are
important [7, 12, 21].
It is known that CLBP accounts for considerable health
care and socioeconomic costs [5, 6, 14]. These health-care
costs are, among other things, related to sick leave and
disability allowance, referrals to general practitioners
and medical specialists, use of allied health care and
pharmaceutical prescriptions for analgesics. Therefore, we
evaluated health-care use on all of these dimensions of
health-care costs. The results of this study show that health-
care use is decreased at long-term follow-up. A marked
reduction of analgesic use is seen and a shift of most
patients is shown from the ‘moderate-severe’ (WHO-steps
1B-3; 65%) to the ‘none-light’ (none and WHO-step 1A;
71%) category of the WHO analgesic ladder. Moreover,
with a reduction in analgesic use a decrease of pain intensity
and pain experience during daily activities (VAS scores) is
shown, as well as maintenance of these results at 2-year
follow-up. In patients with CLBP antidepressants are
sometimes prescribed for pain reduction [selective seroto-
nin reuptake inhibitors (SSRI) and tricyclic antidepressants
(TCA)]. We found at baseline that only 11% used antide-
pressants (4% TCA and 7% SSRI) and at long-term follow-
up a reduction in consumption is seen: only two respondents
(2%) reported to use this medication (2% TCA and none
used SSRI). This implies that the program is successful not
only on health-care use with a reduction in health-care
costs, but also on safety possibly resulting in less adverse
side effects. When the results are extrapolated to the Dutch
adult population a quarter of the patients with CLBP could
benefit from this program and therefore an estimated half of
the health-care costs could be saved.
Limitations of the study
This study has some limitations. The external validity of
the study might be limited, depending to whom the results
are generalized. Since we studied a prospective cohort with
carefully selected patients over a period of time, we have to
restrict the generalization to patients with similar charac-
teristics. The patients included had no indication for a
surgical intervention and they had to confirm that they were
motivated to change their behavior with regard to the back
Fig. 2 Pie charts illustrating
percentages of participants
(n = 85) who use pain
medication, classified in
accordance with the steps in
WHO analgesic ladder [25] and
differentiated in consumption
groups: ‘none-light’ (green) and
‘moderate-severe’ (red)
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pain complaints. Therefore, generalization to the general
population is limited.
We evaluated health-care use by means of self-reported
questionnaires and, therefore, bias could have been intro-
duced. We took this aspect into account in the design of the
study, a structured post-marketing survey, and by asking
the participants to request additional information at general
practitioner or pharmacy if necessary. A possible bias
could have been introduced due to the fact that patients had
to recall what happened in the last year.
The intervention described in this study uses a wide
range of techniques based on principles of CBT. As yet it
is unclear which techniques, or parts of the intervention
are responsible for the observed effect. Therefore, we
studied the intervention as an integral program. The main
aim of the study was to evaluate the stability of positive
outcomes of a short, intensive intervention and its impact
on health-care use. Therefore, we did not evaluate fre-
quently reported cognitive and behavioral factors as fear
of movement, catastrophizing, and anxiety [4, 30–32].
These cognitive behavioral factors contribute, among
other factors, to a certain extent to the main outcome
functioning and quality of life. We showed a long-term
significant improvement on the mental component scale
of the SF36, but a closer exploration of these cognitive
behavioral factors and their impact on functionality is
needed. Moreover, patients attending this program have to
be motivated to change their behavior. Although a
selection criterion for treatment, we neither assessed this
factor in a clear valid and reproducible way at pre-treat-
ment nor assessed it systematically over time. Therefore,
a clear description of ‘motivation to change behavior’ in
the subgroup of CLBP patients benefitting from this
program cannot be given. ‘Readiness or motivation to
change pain-related behavior’ is a multidimensional con-
struct recently described in the literature [33, 34]. As
individuals may vary in their readiness to learn and adopt
new coping skills or self-management strategies it may be
a key element in understanding how participants benefit
or fail to benefit from this program.
Conclusion
In a selected and motivated group of patients with long-
standing CLBP, the results of a short intensive cognitive
behavioral pain management program gained in the first
year are maintained at the 2-year follow-up. Above all, at
follow-up most of the participants are at work, they per-
form a gainful employment, and the results suggested that
the use of both pain medication and health care have
decreased substantially.
Acknowledgments
editorial comments.
The authors thank Mrs. P. G. Anderson for her
Conflict of interest
None.
Open Access
Creative Commons Attribution Noncommercial License which per-
mits any noncommercial use, distribution, and reproduction in any
medium, provided the original author(s) and source are credited.
This article is distributed under the terms of the
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