Dare to Move: Treatment of Movement Phobia in Patient With Low Back Pain
Condition: Low Back Pain
MeSH terms: Back Pain; Low Back Pain
Study type: Interventional

Summary: 
      Unspecific low back pain (LBP) is a major world wide health problem. The purpose of this
      study is to improve the care of LBP.

      Our hypothesis is that Cognitive Behavioural Therapy (CBT) with physical intervention during
      group sessions focusing on fear and avoidance behaviour will be more effective than physical
      therapy alone.

      The study has two arms. Both will receive education related to LBP and appropriate advice
      regarding how to react and behave towards their LBP.

      The main focus in the intervention group will be:

        -  Identifying their fear of movements and perform the frightened movements during the
           group sessions.

        -  Reassuring that gradually normalizing daily activities will not be harmful but rather
           reduce their pain.
    

Detailed description: 
      Cognitive-behavioural treatment is the treatment of choice in the treatment of most patients
      with chronic LBP. Several randomized controlled trials and recent meta-analysis have
      demonstrated the potent effects of CBT.

      The fear and avoidance model developed by Vlaeyen and Linton has been recommended to be
      applied in the treatment of patients with chronic low back pain. No randomized controlled
      study has been published comparing the use of a fear and avoidance treatment with a
      comparison treatment. Such a study is highly warranted to examine if the model actually has a
      superior effect compared to other CBT-based treatments. In addition, it is of vital
      importance to examine whether all patients profit better from such a treatment or whether it
      only will demonstrate superior effect in a subgroup of patients with chronic low back pain.

      PROBLEMS OF INTEREST:

      Main aims are to improve the treatment of patients with chronic LBP by:

        -  1) Testing the effect of a treatment assumed by the international scientific community
           to be the treatment of choice;

        -  2) To develop a diagnostic screening procedure that at an initial examination can
           differentiate patients that need special treatment attention in the form of exposure
           towards feared movements from those who can benefit sufficiently from just receiving
           appropriate advice.

        -  3) To identify the mechanism of change in the treatment of LBP.

      METHODS:

      Subjects will be recruited from general practitioners in the county of Nord-Trøndelag and
      from our department.

      The study is clinical prospective and randomized. Each session will be videotaped. Two
      independent raters will rate three random sessions from both the intervention and
      non-intervention groups. Treatment differentiability will be measured by assessing the amount
      of time (minutes) spent exposing the patients to various movements in the session (ISE).
      According to the manuals, amount of ISE in CBGT (cognitive Behavioural Group Therapy) should
      be zero and between ten to twenty minutes in the CBGT-ISE (cognitive Behavioural Group
      Therapy- In Session Exposure) condition.

      In addition, in both groups the therapists conducting the treatments are instructed to
      measure amount of time devoted to ISE in each session.

      The therapist will rate every session. Three out of six sessions will also be timed and rated
      by two independent raters. The consistency of the time measured by the therapist and the
      independent raters will be compared in order to assure correctness of reported time spent in
      session. The raters will also asses the quality of the sessions. If the ratings are
      consistent across therapists and independent raters, a total ISE score for each treatment
      group will be computed.

      THE TWO ARMS:

      Arm 1: CBGT Patients will be given a manualised group treatment based on a fear and avoidance
      model. A main focus will be identifying fear of movements. The patients will in a spoken
      manner be reassured that they gradually can begin to perform normal daily activities and
      perform movements in a normal manner without using various forms of safety behaviours.
      Dysfunctional thinking patterns will be identified and challenged. Ten to twenty minutes of
      each session will be devoted to reassuring patients that various forms of feared movements
      can be performed in a graded fashion based on a feared hierarchy.

      Arm 2: CBGT-ISE Patients will be given a manualised group treatment based on a fear and
      avoidance model. A main focus will be identifying fear of movements. The patients will in a
      spoken manner be reassured that they gradually can begin to perform normal daily activities
      and perform movements in a normal manner without using various forms of safety behaviours.
      Dysfunctional thinking patterns will be identified and challenged.

      Ten to twenty minutes of each session will be devoted to actually exposing the patients to
      various feared movements and performing these in a graded fashion based on a fear hierarchy.
    

Intervention name(s): Arm 2: CBGT-ISE; Arm 1: CBGT
Intervention type(s): Behavioral; Behavioral
Intervention description(s): Intervention with active performance of the feared movements during group sessions.; Intervention according to previously mentioned methods.
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Single (Outcomes Assessor)
Primary purpose: Treatment
Keywords: Low back pain; Cognitive behavioural therapy; Group therapy; Exposure in session