Cited by 134Musculoskeletal pain and rehabilitationPain Management and TreatmentMedical Practices and Rehabilitation

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A randomized trial of behavioral physical therapy interventions for acute and sub-acute low back pain (NCT00373867)

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George, Steven Z., Zeppieri, Giorgio, Cere, Anthony L., Cere, Melissa R., Borut, Michael S., Hodges, Michael J., Reed, Dalton M., Valencia, Carolina, Robinson, Michael E.·2008·Pain

DOI 10.1016/j.pain.2008.07.029PMC PMC2596955

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Abstract

Psychological factors consistent with fear-avoidance models are associated with the development of chronic low back pain (LBP). As a result, graded activity (GA) and graded exposure (GX) have been suggested as behavioral treatment options. This clinical trial compared the effectiveness of treatment-based classification (TBC) physical therapy alone to TBC augmented with GA or GX for patients with acute and sub-acute LBP. Our primary hypothesis was that GX would be most effective for those with elevated pain-related fear. In total, 108 patients enrolled in this clinical trial and were randomly assigned to receive TBC, GA, or GX. Outcomes were assessed by a blinded evaluator at 4 weeks and by mail at 6 months. The primary outcomes for this trial were disability and pain intensity, and the secondary outcomes were fear-avoidance beliefs, pain catastrophizing, and physical impairment. There were no differences in 4-week and 6-month outcomes for reduction of disability, pain intensity, pain catastrophizing, and physical impairment. GX and TBC were associated with larger reductions in fear-avoidance beliefs at 6 months only. Six-month reduction in disability was associated with reduction in pain intensity, while 6-month reduction in pain intensity was associated with reductions in fear-avoidance beliefs and pain catastrophizing. This trial suggests that supplementing TBC with GA or GX was not effective for improving important outcomes related to the development of chronic LBP.

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Mansell, G., Storheim, K., Løchting, I., Werner, E. L., & Grotle, M. (2017) · Physical Therapy · doi:10.1093/ptj/pzx091 · Cited by 27
Cognitive Mediators of Change in Physical Functioning in Response to a Multifaceted Intervention for Managing Osteoarthritis
Taylor, S. S., Oddone, E. Ž., Coffman, C. J., Jeffreys, A. S., Bosworth, H. B., & Allen, K. D. (2018) · International Journal of Behavioral Medicine · doi:10.1007/s12529-017-9689-5 · Cited by 25
Effects and Mechanisms of a Web- and Mobile-Based Acceptance and Commitment Therapy Intervention for Anxiety and Depression Symptoms in Nurses: Fully Decentralized Randomized Controlled Trial.
Lu, Y., Li, Y., Huang, Y., Zhang, X., Wang, J., Wu, L., & Cao, F. (2023) · Journal of Medical Internet Research · doi:10.2196/51549 · Cited by 24
“This facilitates attempts to account for temporality in the mediation model, an important aspect when examining causality [53,54].”
Short-term effects of thoracic spinal manipulations and message conveyed by clinicians to patients with musculoskeletal shoulder symptoms: a randomized clinical trial
Riley, S. P., Cote, M. P., Leger, R. R., Swanson, B. T., Tafuto, V., Sizer, P. S., & Brismée, J. (2014) · Journal of Manual & Manipulative Therapy · doi:10.1179/2042618613y.0000000066 · Cited by 25
The effectiveness of physiotherapy functional restoration for post-acute low back pain: A systematic review
Richards, M. C., Ford, J. J., Slater, S. L., Hahne, A. J., Surkitt, L. D., Davidson, M., & McMeeken, J. M. (2013) · Manual Therapy · doi:10.1016/j.math.2012.06.005 · Cited by 24
“…(1998), Kankaanpaa et al. (1999), Johnson et al. (2007) and Paoloni et al. (2011), and otherwise included three trials of primarily acute LBP not included in this review, two of which attributed a lack of intervention effect to recruiting an acute population (Hay et al., 2005; George et al., 2008).”
Background
Socioeconomic Status Influences the Relationship between Fear-Avoidance Beliefs Work and Disability
Valencia, C., Robinson, M. E., & George, S. Z. (2010) · Pain Medicine · doi:10.1111/j.1526-4637.2010.01024.x · Cited by 21
Self-citation
Using Intake and Change in Multiple Psychosocial Measures to Predict Functional Status Outcomes in People With Lumbar Spine Syndromes: A Preliminary Analysis
Hart, D. L., Werneke, M. W., Deutscher, D., George, S. Z., Stratford, P. W., & Mioduski, J. E. (2011) · Physical Therapy · doi:10.2522/ptj.20100377 · Cited by 21
Self-citation
A randomized controlled trial of graded exposure treatment (GET living) for adolescents with chronic pain
Simons, L. E., Harrison, L. E., Boothroyd, D. B., Parvathinathan, G., Van Orden, A. R., O'Brien, S. F., Schofield, D., Kraindler, J., Shrestha, R., Vlaeyen, J. W. S., et al. (2024) · Pain · doi:10.1097/j.pain.0000000000003010 · Cited by 19
Effect of Adding McKenzie Syndrome, Centralization, Directional Preference, and Psychosocial Classification Variables to a Risk-Adjusted Model Predicting Functional Status Outcomes for Patients With Lumbar Impairments
Werneke, M. W., Edmond, S. L., Deutscher, D., Ward, J., Grigsby, D., Young, M., McGill, T., McClenahan, B. J., Weinberg, J. R., & Davidow, A. L. (2016) · Journal of Orthopaedic and Sports Physical Therapy · doi:10.2519/jospt.2016.6266 · Cited by 18
Longitudinal Monitoring of Pain Associated Distress With the Optimal Screening for Prediction of Referral and Outcome Yellow Flag Tool: Predicting Reduction in Pain Intensity and Disability
George, S. Z., Li, C., Luo, S., Horn, M. E., & Lentz, T. A. (2020) · Archives of Physical Medicine and Rehabilitation · doi:10.1016/j.apmr.2020.05.025 · Cited by 17
Self-citation
The effect of journal impact factor, reporting conflicts, and reporting funding sources, on standardized effect sizes in back pain trials: a systematic review and meta-regression
Froud, R., Bjørkli, T., Bright, P., Rajendran, D., Buchbinder, R., Underwood, M. R., Evans, D. W., & Eldridge, S. M. (2015) · BMC Musculoskeletal Disorders · doi:10.1186/s12891-015-0825-6 · Cited by 17
Impact of psychosocial factors, pain, and functional limitations on throwing athletes who return to sport following elbow injuries: A case series
Prugh, J., Zeppieri, G., & George, S. Z. (2012) · Physiotherapy Theory and Practice · doi:10.3109/09593985.2012.666632 · Cited by 16
“The FAM has been studied primarily in chronic pain populations, including low back pain (LBP) (Leeuw et al, 2007); however, more recent studies have shown that it is applicable to other musculoskeletal conditions, including shoulder pain and patellofemoral pain syndrome (Leeuw et al, 2007; Mintken, Cleland, Whitman, a…”
Self-citation
Psychological Features and Their Relationship to Movement-Based Subgroups in People Living With Low Back Pain
Karayannis, N. V., Jull, G. A., Nicholas, M. K., & Hodges, P. W. (2017) · Archives of Physical Medicine and Rehabilitation · doi:10.1016/j.apmr.2017.08.493 · Cited by 15
Managing Acute Back Pain Patients to Avoid the Transition to Chronic Pain
Chou, R., & McCarberg, B. H. (2010) · Pain Management · doi:10.2217/pmt.10.7 · Cited by 14
How does reduction in pain lead to reduction in disability in patients with musculoskeletal pain?
Shaygan, M., Böger, A., & Kröner‐Herwig, B. (2019) · Journal of Pain Research · doi:10.2147/jpr.s197533 · Cited by 14
“As these residual scores represent the difference between the follow-up score compared with what was predicted at baseline, they could control for baseline score.(57,58) The residual values are frequently used in studies of mediation.”
MethodResult
Disentangling classification systems from their individual categories and the categoryspecific criteria: an essential consideration to evaluate clinical utility
Fritz, J. M. (2010) · Journal of Manual & Manipulative Therapy · doi:10.1179/106698110x12804993427162 · Cited by 13
Comparison of Combined Motor Control Training and Isolated Extensor Strengthening Versus General Exercise on Lumbar Paraspinal Muscle Health and Associations With Patient-Reported Outcome Measures in Chronic Low Back Pain Patients: A Randomized Controlled Trial
Rosenstein, B., Rye, M., Roussac, A., Naghdi, N., Macedo, L. G., Elliott, J. M., DeMont, R. G., Weber, M. H., Pepin, V., Dover, G. C., et al. (2025) · Global Spine Journal · doi:10.1177/21925682251324490 · Cited by 14
“79 Additionally, a decrease in pain was correlated with decreases in fear-avoidance beliefs and catastrophizing in people with LBP. 80 The MC + ILEX group may have developed a more resilient and positive perception towards their pain condition during the intervention.”
Influential
Catastrophizing, Solicitous Responses From Significant Others, and Function in Individuals With Neuropathic Pain, Osteoarthritis, or Spinal Pain in the General Population
Glette, M., Landmark, T., Jensen, M. P., Woodhouse, A., Butler, S., Borchgrevink, P. C., & Stiles, T. C. (2018) · Journal of Pain · doi:10.1016/j.jpain.2018.03.010 · Cited by 13
Biopsychosocial influence on shoulder pain: Rationale and protocol for a pre-clinical trial
George, S. Z., Staud, R. M., Borsa, P. A., Wu, S. S., Wallace, M. R., Greenfield, W. H., Mackie, L. N., & Fillingim, R. B. (2017) · Contemporary Clinical Trials · doi:10.1016/j.cct.2017.03.005 · Cited by 11
Self-citation
Are Tailored Interventions to Modifiable Psychosocial Risk Factors Effective in Reducing Pain Intensity and Disability in Low Back Pain? A Systematic Review with Meta-Analysis of Randomized Trials
Rabiei, P., Keough, C., Patricio, P., Côté‐Picard, C., Desgagnés, A., & Massé‐Alarie, H. (2025) · Journal of Orthopaedic and Sports Physical Therapy · doi:10.2519/jospt.2025.12777 · Cited by 11
Inter-tester Reliability in Classifying Acute and Subacute Low Back Pain Patients into Clinical Subgroups: A Comparison of Specialists and Non-Specialists. A Pilot Study
Paatelma, M., Karvonen, E., & Heinonen, A. O. (2009) · Journal of Manual & Manipulative Therapy · doi:10.1179/106698109791352166 · Cited by 10
When Matching Fails: Understanding the Process of Matching Pain-Disability Treatment to Risk Profile
Bergbom, S., Boersma, K., & Linton, S. J. (2014) · Journal of Occupational Rehabilitation · doi:10.1007/s10926-014-9558-x · Cited by 10
“Some have shown that subgroups of people with different profiles of psychological variables have equal outcomes of treatment [15, 16], while others have demonstrated differences in treatment response among subgroups [12, 17].”
Background
Chronic Low Back Pain
May, S. (2011) · Springer eBooks · doi:10.1007/978-1-4419-1651-8_16 · Cited by 9
Physical therapist–led interventions based on the biopsychosocial model provide improvement in disability and pain for spinal disorders: A systematic review and meta‐analysis
Miki, T., Kondo, Y., Kurakata, H., Takebayashi, T., & Samukawa, M. (2023) · PM&R · doi:10.1002/pmrj.13002 · Cited by 10
Effect moderators in Internet‐based exposure therapy for fibromyalgia: The role of pain intensity
Hedman‐Lagerlöf, M., Andersson, E., Ljótsson, B., Engelbrektsson, J., Lundbäck, K., Björkander, D., Hedman‐Lagerlöf, E., Flink, I. K., & Axelsson, E. (2022) · European Journal of Pain · doi:10.1002/ejp.2074 · Cited by 7
Cognitive behavioural therapy shown to be an effective and low cost treatment for subacute and chronic low-back pain, improving pain and disability scores in a pragmatic RCT
Hill, J. C., Foster, N. E., & Hay, E. M. (2010) · BMJ Evidence-Based Medicine · doi:10.1136/ebm1085 · Cited by 7
“can be adapted to treat common complaints such as back pain in primary care. Last year a high-profile trial in America”
Background
Treatment for Acute Pain: An Evidence Map
Brasure, M., Nelson, V. A., Scheiner, S., Forte, M. L., Butler, M., Nagarkar, S., Saha, J., & Wilt, T. J. (2019) · doi:10.23970/ahrqepctb33 · Cited by 7
The association between self-efficacy on function and pain outcomes among patients with chronic low back pain managed using the McKenzie approach: a prospective cohort study
Edmond, S. L., Werneke, M. W., Grigsby, D., Young, M., & Harris, G. (2022) · Journal of Manual & Manipulative Therapy · doi:10.1080/10669817.2022.2075202 · Cited by 7
Expanding access to effective psychologically based treatments: Training nurse practitioners yields dividends
Nicholas, M. K. (2014) · Pain · doi:10.1016/j.pain.2014.06.021 · Cited by 6
Directional preference, cognitive behavioural interventions, and outcomes among patients with chronic low back pain
Edmond, S. L., Werneke, M. W., Young, M., Grigsby, D., McGill, T., & McClenahan, B. J. (2019) · Physiotherapy Research International · doi:10.1002/pri.1773 · Cited by 5
Effectiveness of spinal manipulation and biopsychosocial self-management compared to medical care for low back pain: a randomized trial study protocol
Brønfort, G., Delitto, A., Schneider, M., Heagerty, P. J., Chou, R., Connett, J. E., Evans, R., George, S. Z., Glick, R. M., Greco, C. M., et al. (2023) · BMC Musculoskeletal Disorders · doi:10.1186/s12891-023-06549-w · Cited by 6
Self-citation

Authors: George, S. Z., Zeppieri, G., Cere, A. L., Cere, M. R., Borut, M. S., Hodges, M. J., Reed, D. M., Valencia, C., & Robinson, M. E.
Affiliations: University of Florida (US)
University of Florida Health (US)
Corresponding author: George, Steven Z.
ORCID: George, Steven Z.
Zeppieri, Giorgio
Valencia, Carolina
Robinson, Michael E.
Venue: Pain
Publisher: Ovid Technologies (Wolters Kluwer Health)
Published: 2008-11-15
Volume: 140
Issue: 1
Pages: 145-157
ISSN: 0304-3959 (ISSN-L)
DOI: 10.1016/j.pain.2008.07.029
PMC: PMC2596955
OpenAlex: W1984753997
Cited by: 134
References: 56
Citations by year: 2026: 1 · 2025: 5 · 2024: 3 · 2023: 6 · 2022: 4 · 2021: 4 · 2020: 4 · 2019: 7 · 2018: 10 · 2017: 10 · 2016: 5 · 2015: 7 · 2014: 8 · 2013: 13 · 2012: 11
FWCI: 8.41
Type: journal article
Language: en
Open access: green
www.ncbi.nlm.nih.gov
Locations: Pain (publishedVersion)
PubMed (publishedVersion)
PubMed Central (acceptedVersion)
Funders: National Institute of Arthritis and Musculoskeletal and Skin Diseases (AR051128, R03AR051128)
Topics: Health Sciences › Health Professions › Physical Therapy, Sports Therapy and Rehabilitation › Musculoskeletal pain and rehabilitation
Health Sciences › Medicine › Anesthesiology and Pain Medicine › Pain Management and Treatment
Health Sciences › Health Professions › Physical Therapy, Sports Therapy and Rehabilitation › Medical Practices and Rehabilitation
Keywords: low back pain, acute low back pain, subacute low back pain, graded activity, graded exposure, fear-avoidance beliefs, pain catastrophizing, disability, pain intensity, physical impairment
MeSH terms: Acute Disease, Adult, Behavior Therapy, Female, Humans, Male, Pain Measurement, Treatment Outcome, Low Back Pain, Physical Therapy Specialty

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A randomized trial of behavioral physical therapy interventions for acute and sub-acute low back pain (NCT00373867)

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