Psychological Features and Outcomes of The Back School Treatment in Patients With Chronic Non-Specific Low Back Pain. A Randomized Controlled Study.

Psychological features and outcomes
of the Back School treatment in patients with

chronic non-specific low back pain.
A randomized controlled study
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T. PAOLUCCI 1, G. MORONE 2, M. IOSA 2, A. FUSCO 2, R. ALCURI 1,

A. MATANO 3, I. BURECA 3, V. M. SARACENI 1, S. PAOLUCCI 2
Background. Low back pain is a worldwide health

problem, affecting up to 80% of adult population. Psychological factors are involved in its development and
maintenance. Many clinical trials have evaluated the
efficacy of different interventions for chronic nonspecific low back pain. In this field, Back School program has been demonstrated effective for people with
chronic non-specific low back.
Aim. To evaluate the relationship between the effects
of the Back School treatment and psychological features measured by MMPI-II of patients with chronic
non-specific low back pain.
Design. A randomised controlled trial with three and
six-month follow-up.
Setting. Ambulatory rehabilitative university centre.
Population. Fifty patients with chronic non-specific
low back pain out of 77 screened patients.
Methods. Patients were randomly placed in a 3:2 form
and were allocated into two groups (Treatment versus
Control). The Treatment Group participated to an intensive multidisciplinary Back School program (BSG, N.=29),
while the Control Group received medical assistance (CG,
N.=21). Medication was the same in both groups. Then,
patients were subgrouped in those with at least an elevation in one scale of MMPI-II, and those without it. The
Short Form 36 Health Status Survey for the assessment
of quality of life (primary outcome measure), pain Visual
Analogue Scale, Waddel Index and Oswestry Disability
Index were collected at baseline, at the end of treatment,
and at the three and six-month follow-up.
Results. Only the two treated subgroups showed a significant improvements in terms of quality of life, disability and pain. Among treated subjects, only those
with at least one scale elevation in MMPI-II showed
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EUR J PHYS REHABIL MED 2012;48:245-53
Corresponding author: G. Morone, I.R.C.C.S. - Fondazione Santa

Lucia, via Ardeatina 306, 00179 Rome, Italy.
E-mail: g.morone@hsantalucia.it
Vol. 48 - No. 2
1Department of Physical Medicine and Rehabiltation

Policlinico Umberto I, Sapienza University, Rome, Italy
2Movement and Brain Laboratory
Fondazione Santa Lucia IRCCS, Rome, Italy
3Department of Neuropsychology
Fondazione Santa Lucia IRCCS, Rome, Italy
also a significant improvement in terms of Short Form

36 mental composite score and relevant subscores.
Conclusion. These results suggest that Back School program has positive effects, even in terms of mental components of quality of life in patients with scale elevations of MMPI-II. Probably these findings are due to its
educational and cognitive-behavioural characteristics.
Clinical rehabilitation impact. Because of its educational purposes, the Back School treatment can have positive effects also on the mental status of patients with low
back pain when it affects their psychological features.
Key words: Low back pain - Rehabilitation - Treatment

outcome.
ow back pain (LBP) is a common worldwide health

problem with high impact of related disability and
economical costs.1 The lifetime prevalence is up to
84%, and chronic non-specific low back pain is estimated approximately to 23%.2 Chronic LBP is defined
as a pain persisting for at least 12 weeks, while nonspecific addresses to a diagnosis of exclusion 3 and
indicates that no structures have been identified as
causing the pain. Under this umbrella definition many
common diagnoses are grouped, such as lumbago,
EUROPEAN JOURNAL OF PHYSICAL AND REHABILITATION MEDICINE
245
Back School treatment
could imply elevations into the scores of MMPI-II.21

Some previous studies have already examined the relationship between personality profiles, assessed by
MMPI-II, and treatment outcomes.22-24 Nevertheless,
at the best of our knowledge, correlations among
psychological profiles and efficacy of an educational
and rehabilitative treatment have never been analyzed in chronic non-specific low back pain.
The aim of this study was to evaluate the relationship
between the effects of the Back School treatment and
psychological features measured by MMPI-II of patients
with chronic non-specific low back pain.
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myofascial syndromes, muscle spasms, mechanical

LBP, back sprain and back strain.2
The biopsychosocial model of illness, proposed by
Engel in 1977,4 has gained widespread acceptance
within the spine care community.5 In this model, patients functioning is influenced by biological, psychological, and social factors. It is well demonstrated
that depression, anxiety, distress, and related emotions have an important impact on back pain disability, especially in the development of persisting
LBP.6-8 Furthermore, it develops far more frequently
in patients having a high level of fear avoidance, psychological distress, disputed compensation claims,
involvement in litigation, and job dissatisfaction.9
Back School is an interesting and promising exercise program to treat people with chronic low back
pain.10, 11 A Cochrane review including 3584 patients
with chronic low back pain showed that there is
moderate evidence suggesting that back schools, in
an occupational setting, reduce pain, and improve
function and return-to-work status, in the short and
intermediate-term, compared to exercises, manipulation, myofascial therapy, advice, placebo or waiting list controls.12 Back School consists of an educational program and physical exercises, in which all
lessons were given to groups of patients and supervised by a therapist or medical specialist.13
The psycho-social aspect is considered as a crucial knot for the development of back pain. Communication has been more and more often studied as
a central part of the health care professional/patient
relationship. In this way, Back schools can help the
health management of the people with LBP,14 in particular when provided by a multidisciplinary team
and with brief education.15
The Minnesota Mutiphasic Personality Inventory-II (MMPI-II) is one of the most commonly used
self-report instrument in the psychological evaluation of subjects. It is standardized also for patients
with chronic pain and for personality assessment in
medical and mental health settings.16-18 This scale
provides an overview of personality individual differences and it has been delineated and validated on
the basis of the previous MMPI.19
Many studies have attempted to predict which
people have a propensity in the development of the
pain chronicity. Pulliam et al. have found an association between higher scores in the scale of anxiety
and chronic pain status.20 However, there is no reliable evidence that chronic LBP could be preceded or
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Materials and methods
Study design and data collection
We performed a single blind randomised controlled trial with three- and six-month follow-up. This
study was approved by local ethical committee and
participants signed informed consent. Fifty-one patients were enrolled and randomly inserted into
treatment group (TG, N.=29) or control group (CG,
N.=21) in a ratio of 3:2. We have chosen this ratio
because in the previous year we have treated around
60% of patients with chronic low back pain of those
assessed and resulted includable into a Back School
Program. The remaining 40% was excluded only for
the lack of financial resources. Hence, we decided
to maintain this proportion also into the design of
the present study. The concealed randomization was
performed by means of sealed envelopes extracted
every 15 patients: five patients were allocated in a
treatment group performing Back School Program,
other four patients in another similar treated group,
and the last six in the control group 25 (Figure 1). In
order to investigate the relationships between psychological features and rehabilitative outcomes, we
stratified patients in those with elevated scores in
one or more scales of MMPI-II (ES group) and those
with no elevations in anyone of the scores of MMPIII (NES), on the basis of the Italian standardization.26
Inclusion criteria were: age between 18 and 80
years and a diagnosis of chronic non-specific low
back pain. Exclusion criteria were: acute low back
pain, low back pain due to specific causes, presence
of reumathological, neurological or oncological concomitant diseases, previous back surgery, severe
cognitive impairments and pregnancy.
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Subject screened for study

N=77
Excluded N=3:
out for exclusion
criteria N=3
Enrolled into study
N=74
Excluded N=1:
refuse protocol
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Randomized
N=73
Subject assigned to
back school group
(BSG) N=44
Received 10 session in 1 month
(around 3 times/week N=44);
MMPI-II performed.
Excluded (N=15):
8 no sufficient answer to MMPI-II
4 refuse MMPI-II
3 lost to T-end evaluation:
unclear/no reasons (N=1);
No time (N=2)
Subject assigned to
control group
(CG) N=29
Received medical assistence
for one month;
MMPI-II performed.
Excluded (N=8):
5 no sufficient answer
to MMPI-II
3 refuse MMPI-II
Presence of
almost 1 MMPI-II
scale score
elevation (N=18)
No presence of
MMPI-II scale
score elevation
(N=11)
Presence of
almost 1 MMPI-II
scale score
elevation (N=10)
No presence of
MMPI-II scale
score elevation
(N=11)
Last 3 months
follow-up (N=0)
Last 3 months
follow-up (N=0)
Last 3 months
follow-up (N=0)
Last 3 months
follow-up (N=0)
Last 6 months
follow-up (N=0)
Last 6 months
follow-up (N=0)
Last 6 months
follow-up (N=0)
Last 6 months
follow-up (N=0)
Analyzed (N=18)
Excluded (N=0)
Analyzed (N=11)
Excluded (N=0)
Analyzed (N=10)
Excluded (N=0)
Analyzed (N=11)
Excluded (N=0)
Figure 1.Consort flow-chart for this study.
Outcome measures
Socio-demographic and clinical data and MMPIII were collected at the baseline. Specific scales for
Vol. 48 - No. 2
quality of life (Short Form Health Status; SF-36), disability (Oswestry Disability Index, ODI, and Waddell
Index, WI), and pain perception (Visual Analogue
Scale, VAS) were assessed at the baseline (T0), at the
247
The Oswestry Disability Index (ODI) is the most

common measure for an outcome in patients with
LBP evaluating the degree of functional impairment
in activities of daily life caused by pain.32-34 ODI was
successfully translated into Italian language.35
Study intervention
The Back School program was an intensive four
weeks intervention carried out by a multidisciplinary
professional team. It was conducted in a rehabilitation center and formed by 10 intervention sessions.
After a first theoretical lesson, subjects were treated
three times per week for three weeks. All sessions
lasted one hour. Each group included four or five
participants.
In the first session, participants received an education about general anatomical information related
to spine, its functioning and ergonomic positions in
daily living. Teachers (physicians) also gave information about pain concepts, psychological aspects
and stress management, workplace situation and
sport activities. Another 9 sessions were carried out
by physiotherapists. These sessions were dedicated
to exercises based on the re-education of breathing,
self stretching trunk muscles, erector spine reinforcement, abdominal reinforcement and postural exercises. Ergonomic use of the spine in daily life with
self correction and how to cope with spine stressing
positions during work was explained. Teachers were
instructed to emphasize simulations of the daily living environment and to involve patients in an active manner during lessons. Pamphlets were given
to participants with further explanations regarding
theoretical aspects, exercise protocol proposed in
exercise programs, information with images of ergonomic use of the spine in daily work and recreation,
such as suggested posture at work, the correct way
to transport weights, the correct manner to carry out
some daily activity such as dressing, eating, bathing,
grooming or other recreational situations like gardening.
Control group (CG), including 21 participants,
was undertaken to medical treatment (NSAIDs and
myorelaxant) self administered during the period of
this study under physician supervision similarly to
the treatment group. Physicians were instructed to
not start or use any new therapy during the study using different drugs (antidepressants, antiepileptics or
other) and if necessary patients were dropped out.
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end of the treatment program (Tend) and at three

(T3m) and six months (T6m) of follow up.
MMPI-II is a wide spectrum test that evaluates the
principal structural personality characteristics and
emotional disorders. The questionnaire is composed of
567 true-false items, distributed among four scales (validity, clinical, content and supplementary scales). The
validity scales serve to confirm the accuracy and sincerity with which the subject filled the questionnaire.
Base clinical scales measure the following constructs:
hypochondria, depression, hysteria, psychopathic deviation, masculinity-femininity, paranoid, psycoasthenia, schizophrenia, mania, social introversion. Content
scales allow to describe different personality variables:
anxiety, fears, obsession, depression, health preoccupation, bizarre thought, anger, cynicism, antisocial
patterns, a type, low self esteem, social disadvantage,
family problems, work difficulty, negative treatment
indicators.16-18 We used the K-corrected T. scores with
the Italian version of the MMPI-II.25
The primary outcome measure of this study was
the quality of life assessed by mean the SF-36 that
is a generic health scale collecting practical, reliable, and valid information about patients functional
health and well-being.26 It includes 36 items summarized in two measures related to physical and mental health. The physical heath is represented by four
domains: physical function (PF), physical role (PR),
bodily pain (BP), and general health (GH). Emotional health includes mental health (MH), social function (SF), emotional role (RE) and vitality domains
(VT). Each scale ranges from 0 to 100 (worst and best
health state, respectively).27, 28 Validity and reliability
of Italian version of SF-36 is well documented.29
The Visual Analogue Scale (VAS) is a simple, robust, sensitive and reproducible instrument that enables the patients to express their pain intensity as
numerical values. It consists of a line, 100 mm long,
whose ends are labelled as the extremes (no pain
and pain as bad as it could be); presenting vertical lines each centimetre without numerical references.30
Waddell Disability Index (WI) is a scale for disability assessment including nine parameters: pain
experienced during sitting, travelling, standing,
walking and lifting weights; and the need (due to
pain) to put on or remove footwear; the presence of
sleep disturbance, life restriction and sexlife restriction. The maximum score is 9 points. A score >5
indicates significant disability.31
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Table I.Baseline characteristics.

Back School Group
Characteristics at baseline
Age
Gender
N. acute events
SF36-PCS
SF36-MCS
WI
ODI
VAS
Control group
NES
ES
NES
ES
58.013.1
6 m; 5 f
2.90.8
39.1 (10.3)
47.1 (14.6)
4 (2)
24 (42)
6 (4)
6015.7
7 m; 11 f
3.30.6
41.2 (9.2)
42.7 (15.3)
3 (3)
28 (18)
7 (2)
56.112.9
4 m; 7 f
3.40.5
46.1 (12.0)
50.3 (7.3)
1 (1)
12 (13)
7 (2)
58.414.9
2 m; 8 f
3.50.5
40.4 (6.2)
26.8 (18.9)
4 (1)
34 (10)
8 (1)
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Baseline characteristics for the four groups: mean standard deviation of age and median and interquartile range for the other characteristics. Number of
acute events in the last 12 months are also reported.
Table II.Quality of life.
BSG
PCS
NES
Baseline
Median value (interquartile range)
Analysis of Friedman
39.1 (10.3)
End of treatment 42.3 (9.6)
3 months
f-up
6 months
f-up
c2
p
MCS
ES
41.2
(9.2)
41.1
(9.0)
45.3 (4.5)
45.9 (11.6)
45.0 (8.8)
46.7 (13.1)
21.27
<0.001
13.80
0.003
NES
47.1
(14.6)
50.6
(17.0)
48.5
(19.9)
52.9
(7.7)
6.80
0.079
CG
PCS
ES
42.7 (15.3)
48.7
(8.8)
49.3 (10.9)
47.7 (11.4)
10.33
0.016
NES
46.1
(12.0)
46.6
(12.5)
42.8
(10.6)
46.3
(11.5)
0.41
0.938
ES
40.4
(6.2)
40.0
(5.1)
41.1
(7.4)
39.6
(6.8)
0.94
0.816
MCS
NES
50.3
(7.3)
52.1
(6.4)
50.5
(10.7)
48.9
(18.5)
2.24
0.525
ES
26.8
(18.9)
28.4
(19.6)
27.0
(17.1)
28.6
(23.7)
3.03
0.347
Medians and inter-quartile range for the Physical and Mental Composite Scores of SF-36 (PCS and MCS, respectively) for Back School Group (BSG) and
Control Group (CG) divided according to the presence (ES) or absence (NES) of elevation into MMPI-II scale scores. In the last two rows the results of
Friedmans analysis for each subgroup (in bold if P<0.05).
Statistical analysis
Baseline characteristics and scale scores were reported in Table I. Median values and inter-quartile
range (i.e., the difference between third and first
quartile) were computed and reported in Table II
for the primary outcome measures. In the Figures,
mean and standard error (because of the high intersubjects variability) were reported. Kruskal-Wallis
analysis was used for main comparisons among the
four groups (BSG-NES, BSG-ES, CG-NES, CG-ES).
Mann-Whitney U test was performed for comparisons between main groups at baseline (BSG vs. CG).
Friedmans analysis were used to assess the significance of differences recorded along time. Repeated
measures analysis of variance was performed on
SF36-PCS and SF36-MCS to take into account the
effects of time (within factor), treatment (BSG vs.
Vol. 48 - No. 2
CG), presence or not of elevations on MMIP-II scale

scores (ES vs. NES), and the interactions among
these two factors. Differences were considered significant if P<0.05 and highly significant if P<0.001.
An intention to protocol analysis was performed.
Results
Fifty patients (out of the seventy-seven screened)

entered into study: 29 out of 41 into treatment
group (TG) and 21 out of 29 into control group
(CG). Eleven patients in TG were excluded from
the study because they had not a sufficient number
of answers to the MMPI-II test (N.=8), they refused
to perform it (N.=4) or they did not conclude the
protocol (N.=3). On the other hand, eight patients
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50
45
40
NES
ES
Baseline
End of
treatment
3 months
follow-up
6 months
follow-up
45
40
NES
ES
35
Baseline
End of
treatment
3 months
follow-up
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35
Mental composite score
50
Physical composite score
6 months
follow-up
Figure 2.Primary outcome measures. On the top panel the Physical Composite Score and on the below panel the Mental Composite Score
of SF-36 recorded for subjects with NES (black) and ES (grey).
in CG were excluded from the study because they

had not a sufficient number of answers to the MMPI-II test (N.=5) or they refused it (N.=3). A cut-off
criteria for defining a sufficient number of answers
of MMPI-II were a variable response inconsistency
and true response inconsistency >80 and Cannot
Say Raw scores >30.36
At baseline, 29 out of the 50 participants (58%) resulted with an elevation in at least one scale of MMPI-II. One elevation was noted in 13 subjects (26%,
9 of them with hypochondria), and two or more elevations in 16 subjects (32%, with hypochondria, depression, hysteria, paranoia as the most commonly
noted). Nineteen patients out of these 29 ones were
included into BSG and 10 into CG.
The mean ages standard deviations, gender,
baseline values of primary and secondary outcome
measures and number of acute pain events reported
in the last year were reported in Table I for the four
subgroups of patients. There were no statistical differences for age among the four subgroups (2=1.23,
P=0.746).
At baseline, also the scores recorded for participants included into BS-treatment were not significantly different from those recorded for control
group (CG) in terms of SF36-PCS (P=0.191), SF36MCS (p=0.852), WI (p=0.185), OSW (p=0.113), and
VAS (p=0.195). Conversely, some differences were
recorded in terms of OSW (p=0.014) and SF36-MCS
(p=0.016) between ES and NES. However, these
250
differences were not significant when the two BSsubgroups were compared (OSW: P=910; SF36MCS: P=0.445), but only due to differences between
untreated subgroups (OSW: P=0.001, SF36-MCS:
P=0.024). No other differences resulted significant
between groups at baseline.
Primary outcome measure: quality of life
Baseline assessment
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The median values and inter-quartile ranges

recorded for the physical and mental composite
scores of SF-36 were reported in Table II. Analysing the SF36-PCS and SF36-MCS by means of
Friedmans analyses, on each sub-group of subjects, significant improvements across time were
recorded only for the two BS-subgroups, but not
for the control subgroups (Table II). The differences in terms of SF36-PCS were highly significant
for BSG-NES and significant for BSG-ES, whereas
the SF36-MCS significantly varied only for BSG-ES.
Figure 2 shows the SF36-PCS and SF36-MCS scores
for BS-subgroups recorded along time. The SF36PCS increased from baseline to the end of treatment
in BSG-NES, and it continued to increase also at
follow-ups. Conversely, in the same treatment period, it slightly decreased in BSG-ES, and it increased
only during follow-up.
A reduction of SF36-MCS at six-month followup was observed in BSG-NES. As expected, neither
composite scores nor sub-scores of SF-36 resulted
significantly varied in CG (Tables II, III). Conversely,
the physical sub-scores resulted improved in both
BS-subgroups. More mental sub-scores resulted im-
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Table III.Improvement in domains of quality of life and reduction in disability and pain.
Table IV.Factors affecting quality of life.
Friedmans analysis (c2, P)
Repeated measures anova
BSG-NES
BSG-ES
CG-NES
CG-ES
17.81
<0.001
5.12
0.163
17.42
0.001
12.17
0.007
10.47
0.015
0.75
0.861
5.87
0.118
4.81
0.186
20.4
<0.001
15.64
0.001
23.17
<0.001
9.16
0.027
9.53
0.023
22.21
<0.001
9.96
0.019
21.98
<0.001
4.40
0.222
14.43
0.002
9.06
0.029
12.32
0.006
18.28
<0.001
23.40
<0.001
0.81
0.846
0.79
0.852
5.83
0.120
5.07
0.166
5.08
0.166
4.20
0.241
2.50
0.475
1.03
0.794
0.69
0.875
2.28
0.516
1.35
0.716
3.72
0.293
1.50
0.682
1.47
0.689
5.85
0.119
2.04
0.564
4.05
0.256
4.45
0.216
0.71
0.871
1.32
0.724
3.07
0.381
3.17
0.366
PF
RP
BP
GH
Waddel Index
Oswestry Disability Index
Pain Visual Analogue Scale
Results of Friedmans Analysis performed for each subgroup for primary

and secondary outcome measures. The subscores of SF-36 are PF: Physical
Function; PR: Physical Role; BP: Bodily Pain; GH: General Health; VT: Vitality; SF: Social Function; RE: Emotional Role; MH: Mental Health; assessed
for BSG: Back School Group, CG: Control Group; ES: elevation on scales of
MMPI-II; NES: absence of elevation on scales of MMPI-II.
proved for BSG-ES than for BSG-NES (Table III). It

explains the significant improvement in terms of
overall SF36-MCS found only in BSG-ES.
These results were confirmed by a repeated measures analysis of variance performed on all participants. Time and interaction between time and treatment resulted the factors that significantly affected
SF36-PCS, whereas SF36-MCS was affected by elevations in MMPI-II scale (ES vs. NES), and by the interactions between time and treatment and between
treatment and elevations (Table IV).
Secondary outcome measures: disability and pain
Highly significant improvements were also observed in terms of WI, ODI, and VAS for BSG-NES
(P0.001, Figure 3 and Table III). The improvements
for BSG-ES were highly significant in terms of ODI
and VAS (P0.001) and significant in terms of WI
(P<0.05).
Vol. 48 - No. 2
6.82
0.01
0.50
6.59
0.74
1.21
0.77
<0.001
0.943
0.484
<0.001
0.394
0.309
0.513
1.70
2.73
6.49
4.20
5.04
1.05
0.94
0.170
0.105
0.014
0.007
0.030
0.374
0.426
Oswestry disability index
ME
MCS
Results of repeated measures analysis of variance (in bold if P<0.05) performed on Physical (PCS) and Mental Composite Scores (MCS) of SF-36 of
all the participants, using as factors between subjects the treatment (Back
School vs. Control group), the elevations on MMPI-II scale scores (presence
vs absence) and using time as factor within subjects.
NES
ES
3
2
1
0
Waddel disability index
RE
Time
Treatment
Elevations on scale
Time*Treatment
Treatment*Elevations
Time* Elevations
Time*Treatment*Elevations
45
40
35
30
25
20
15
10
5
0
NES
ES
Pain visual analogue scale
SF
PCS
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VT
NES
ES
4
2
0
Baseline
End
of treatment
3 months
follow-up
6 months
follow-up
Figure 3.Secondary outcome measures. From top to below: Oswestry Disability Index, Waddel Disability Index, Pain Visual Analogue Scale for subjects with NES (black) and ES (grey).
251
Discussion
the importance of an adequate rehabilitation program

carried out by a multidisciplinary team, that may provide positive effects for all patients and not only those
with high disability.40 Psychological features, such as
fear and beliefs leading to avoidance behaviour, have
an important role in the development of chronic disability in patients with LBP.41 Behavioural avoidance
can cause a number of physical and psychological
troubles: a reduction of physical activity can result in
reduced flexibility and loss of muscle strength; this
may lead to an increment of pain, a reinforcement of
the avoidance cycle. Activity avoidance means that
there are less opportunities to calibrate the pain sensation against the pain experience.42
The Back School treatment improved the quality
of life of patients with an elevation in MMPI-II only
at follow-up and not immediately after treatment. It
should be also noted that at baseline this subgroup of
subjects showed a reduced quality of life more related
to mental than physical aspects. So, our results may
be due to the time needed to transfer into a physical
improvement the mental benefit and the knowledge
acquired during the Back School program.15 Then, a
slight reduction of SF36-MCS in subjects with one or
more elevations at MMPI-II evaluation was observed
at six-month follow-up in respect of three-month follow-up. Further studies, involving a longer period of
follow-up, are needed to verify if this improvement is
maintained along time in these people.
Limitations of our study were the reduced sample
size, the lack of specific tools of evaluation to exactly measure anxiety, fear/avoidance and depression
(psychological factors already shown as correlated
with low back pain) and the absence of a progressive assessments of MMPI-II.
In conclusion, patients with chronic non-specific
low back pain presenting elevation of one or more
scale scores of MMPI-II may benefit by specific educational exercises, such as Back School Program,
similarly to other patients in terms of physical improvement and even more in terms of mental improvement.
IN
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H DI
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The main purpose of this study was to investigate

if the rehabilitation outcomes of a Back School treatment for people with chronic low back pain can be
affected by their psychological features. Participants
were treated through an educational Back School
program of exercises or with pharmacological aids
and stratified into two groups on the basis of the
presence or absence of one or more elevations on
MMPI-II basic scales.
Our results showed that the Back School treatment
was significantly effective for both groups, independently by the presence or not of an elevation in MMPI-II scale. These improvements were observed in
treated subgroups in terms of quality of life, disability
and pain, while they were absent in both control
subgroups. Probably, the most interesting result of
this study was the higher improvement for the BSG
subjects with at least one elevation on scale at MMPIII in terms of Mental Composite Score of SF-36.
It should be noted that our Back School program
carefully took into account behavioural aspects. This
may be the reason for the effectiveness of the treatment in people with one or more elevations, in particular in terms of physical and especially mental
components of quality of life.
Into a recent review, fear, avoidance and anxiety
were highlighted as important aspects in the risk of
the chronicity.37 It should be noted that in our study,
the anxiety profile was highly represented.
Previous studies found that the relief after medical treatment was less effective in patients with psychological disturbances.38, 39 As well, McCreary et al.
have found that unaltered mental profile showed
better responses to prescribed medical treatment
in terms of pain relief and ability improvement.23
Conversely, our results showed that the presence of
one or more elevation into the score of MMPI-II assessment did not lead to poor outcomes. It is noteworthy that our Back School treatment was based
on a multidisciplinary educational intervention: it is
conceivable that it was effective in improving the
mental health of people with elevations of MMPI
scores for its educational characteristics and cognitive-behavioural principles.
The fact that the rehabilitation with a Back School
was found effective in both groups of patients with
or without elevations of the MMPI-II scores was in accordance with some other studies.5, 23 This highlights
PAOLUCCI
252
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Vol. 48 - No. 2
Received on February 15, 2011.

Accepted for publication on July 15, 2011.
Epub ahead of print on November 18, 2011.
253

Psychological Features and Outcomes of The Back School Treatment in Patients With Chronic Non-Specific Low Back Pain. A Randomized Controlled Study.

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Psychological Features and Outcomes of The Back School Treatment in Patients With Chronic Non-Specific Low Back Pain. A Randomized Controlled Study.

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Psychological features and outcomes

of the Back School treatment in patients with

T. PAOLUCCI 1, G. MORONE 2, M. IOSA 2, A. FUSCO 2, R. ALCURI 1,

Background. Low back pain is a worldwide health

EUR J PHYS REHABIL MED 2012;48:245-53

Corresponding author: G. Morone, I.R.C.C.S. - Fondazione Santa

1Department of Physical Medicine and Rehabiltation

also a significant improvement in terms of Short Form

Key words: Low back pain - Rehabilitation - Treatment

ow back pain (LBP) is a common worldwide health

EUROPEAN JOURNAL OF PHYSICAL AND REHABILITATION MEDICINE

Back School treatment

could imply elevations into the scores of MMPI-II.21

myofascial syndromes, muscle spasms, mechanical

Materials and methods

Study design and data collection

EUROPEAN JOURNAL OF PHYSICAL AND REHABILITATION MEDICINE

Subject screened for study

Back School treatment

Figure 1.Consort flow-chart for this study.

EUROPEAN JOURNAL OF PHYSICAL AND REHABILITATION MEDICINE

Back School treatment

The Oswestry Disability Index (ODI) is the most

end of the treatment program (Tend) and at three

EUROPEAN JOURNAL OF PHYSICAL AND REHABILITATION MEDICINE

Table I.Baseline characteristics.

Table II.Quality of life.

Median value (interquartile range)

End of treatment 42.3 (9.6)

Back School treatment

CG), presence or not of elevations on MMIP-II scale

Fifty patients (out of the seventy-seven screened)

EUROPEAN JOURNAL OF PHYSICAL AND REHABILITATION MEDICINE

Back School treatment

Mental composite score

in CG were excluded from the study because they

The median values and inter-quartile ranges

EUROPEAN JOURNAL OF PHYSICAL AND REHABILITATION MEDICINE

Table IV.Factors affecting quality of life.

Friedmans analysis (c2, P)

Repeated measures anova

Oswestry Disability Index

Pain Visual Analogue Scale

Results of Friedmans Analysis performed for each subgroup for primary

proved for BSG-ES than for BSG-NES (Table III). It

Oswestry disability index

Waddel disability index

Pain visual analogue scale

Back School treatment

EUROPEAN JOURNAL OF PHYSICAL AND REHABILITATION MEDICINE

Back School treatment

the importance of an adequate rehabilitation program

The main purpose of this study was to investigate

EUROPEAN JOURNAL OF PHYSICAL AND REHABILITATION MEDICINE

for the management of chronic nonspecific low back pain. Eur

Back School treatment

Received on February 15, 2011.

EUROPEAN JOURNAL OF PHYSICAL AND REHABILITATION MEDICINE

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