Psychological Features and Outcomes of the Back School Treatment in Patients With Chronic Non-specific Low Back Pain. a Randomized Controlled Study

Vol. 48 - No. 2 EUROPEAN JOURNAL OF PHYSICAL AND REHABILITATION MEDICINE 245

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

chronic non-specific low back pain.A randomized controlled study

also a significant improvement in terms of Short Form 36 mental composite score and relevant subscores.Conclusion. These results suggest that Back School pro-gram has positive effects, even in terms of mental com-ponents of quality of life in patients with scale eleva-tions of MMPI-II. Probably these findings are due to its educational and cognitive-behavioural characteristics.Clinical rehabilitation impact. Because of its education-al purposes, the Back School treatment can have posi-tive 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.

Low 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 esti-mated approximately to 23%.2 Chronic LBP is defined as a pain persisting for at least 12 weeks, while non-specific 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,

1Department of Physical Medicine and RehabiltationPoliclinico Umberto I, Sapienza University, Rome, Italy

2Movement and Brain LaboratoryFondazione Santa Lucia IRCCS, Rome, Italy

3Department of NeuropsychologyFondazione Santa Lucia IRCCS, Rome, Italy

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

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. Psy-chological factors are involved in its development and maintenance. Many clinical trials have evaluated the efficacy of different interventions for chronic non-specific low back pain. In this field, Back School pro-gram 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 fea-tures 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 inten-sive 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 eleva-tion 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 sig-nificant improvements in terms of quality of life, dis-ability and pain. Among treated subjects, only those with at least one scale elevation in MMPI-II showed

Corresponding author: G. Morone, I.R.C.C.S. - Fondazione Santa Lucia, via Ardeatina 306, 00179 Rome, Italy. E-mail: [email protected]

Anno: 2012Mese: JuneVolume: 48No: 2Rivista: EUROPEAN JOURNAL OF PHYSICAL AND REHABILITATION MEDICINECod Rivista: EUR J PHYS REHABIL MED

Lavoro: 2515-EJPRMtitolo breve: Back School treatmentprimo autore: PAOLUCCIpagine: 245-53

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PAOLUCCI BACk SCHOOL TREATMENT

246 EUROPEAN JOURNAL OF PHYSICAL AND REHABILITATION MEDICINE June 2012

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, pa-tient’s functioning is influenced by biological, psy-chological, and social factors. It is well demonstrated that depression, anxiety, distress, and related emo-tions have an important impact on back pain dis-ability, especially in the development of persisting LBP.6-8 Furthermore, it develops far more frequently in patients having a high level of fear avoidance, psy-chological distress, disputed compensation claims, involvement in litigation, and job dissatisfaction.9

Back School is an interesting and promising exer-cise 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, manipu-lation, myofascial therapy, advice, placebo or wait-ing list controls.12 Back School consists of an educa-tional program and physical exercises, in which all lessons were given to groups of patients and super-vised by a therapist or medical specialist.13

The psycho-social aspect is considered as a cru-cial knot for the development of back pain. Commu-nication 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 par-ticular when provided by a multidisciplinary team and with brief education.15

The Minnesota Mutiphasic Personality Invento-ry-II (MMPI-II) is one of the most commonly used self-report instrument in the psychological evalua-tion 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 dif-ferences 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 asso-ciation between higher scores in the scale of anxiety and chronic pain status.20 However, there is no reli-able evidence that chronic LBP could be preceded or

could imply elevations into the scores of MMPI-II.21 Some previous studies have already examined the re-lationship 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 ana-lyzed 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.

Materials and methods

Study design and data collection

We performed a single blind randomised control-led trial with three- and six-month follow-up. This study was approved by local ethical committee and participants signed informed consent. Fifty-one pa-tients 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 psy-chological 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 MMPI-II (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 con-comitant diseases, previous back surgery, severe cognitive impairments and pregnancy.

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BACk SCHOOL TREATMENT PAOLUCCI


quality of life (Short Form Health Status; SF-36), dis-ability (Oswestry Disability Index, ODI, and Waddell Index, WI), and pain perception (Visual Analogue Scale, VAS) were assessed at the baseline (T0), at the

Outcome measures

Socio-demographic and clinical data and MMPI-II were collected at the baseline. Specific scales for

Figure 1.—Consort flow-chart for this study.

Presence ofalmost 1 MMPI-II

scale scoreelevation (N=18)

Last 3 monthsfollow-up (N=0)








Analyzed (N=18)Excluded (N=0)




No presence ofMMPI-II scalescore elevation

(N=11)

Presence ofalmost 1 MMPI-II

scale scoreelevation (N=10)

No presence ofMMPI-II scalescore elevation

(N=11)

Subject assigned toback school group

(BSG) N=44Received 10 session in 1 month(around 3 times/week N=44);

MMPI-II performed.Excluded (N=15):

8 no sufficient answer to MMPI-II4 refuse MMPI-II

3 lost to T-end evaluation:unclear/no reasons (N=1);

No time (N=2)

Subject assigned tocontrol group

(CG) N=29Received medical assistence

for one month;MMPI-II performed.

Excluded (N=8):5 no sufficient answer

to MMPI-II3 refuse MMPI-II

Excluded N=1:refuse protocol

Excluded N=3:out for exclusioncriteria N=3

Subject screened for studyN=77

Enrolled into studyN=74

RandomizedN=73

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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 rehabilita-tion 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 edu-cation about general anatomical information related to spine, its functioning and ergonomic positions in daily living. Teachers (physicians) also gave infor-mation 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 reinforce-ment, abdominal reinforcement and postural exer-cises. 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 liv-ing environment and to involve patients in an ac-tive manner during lessons. Pamphlets were given to participants with further explanations regarding theoretical aspects, exercise protocol proposed in exercise programs, information with images of ergo-nomic 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 gar-dening.

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 us-ing different drugs (antidepressants, antiepileptics or other) and if necessary patients were dropped out.

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 (va-lidity, clinical, content and supplementary scales). The validity scales serve to confirm the accuracy and sin-cerity with which the subject filled the questionnaire. Base clinical scales measure the following constructs: hypochondria, depression, hysteria, psychopathic de-viation, masculinity-femininity, paranoid, psycoasthe-nia, schizophrenia, mania, social introversion. Content scales allow to describe different personality variables: anxiety, fears, obsession, depression, health preoc-cupation, 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, relia-ble, and valid information about patients’ functional health and well-being.26 It includes 36 items summa-rized in two measures related to physical and men-tal health. The physical heath is represented by four domains: physical function (PF), physical role (PR), bodily pain (BP), and general health (GH). Emotion-al health includes mental health (MH), social func-tion (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, ro-bust, sensitive and reproducible instrument that ena-bles 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 verti-cal lines each centimetre without numerical refer-ences.30

Waddell Disability Index (WI) is a scale for dis-ability 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 restric-tion. The maximum score is 9 points. A score >5 indicates significant disability.31

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CG), presence or not of elevations on MMIP-II scale scores (ES vs. NES), and the interactions among these two factors. Differences were considered sig-nificant 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

Statistical analysis

Baseline characteristics and scale scores were re-ported 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 inter-subjects 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 compari-sons between main groups at baseline (BSG vs. CG). Friedman’s analysis were used to assess the signifi-cance 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.

Table I.—�Baseline characteristics.

Characteristics at baselineBack School Group Control group

NES ES NES ES

Age 58.0±13.1 60±15.7 56.1±12.9 58.4±14.9Gender 6 m; 5 f 7 m; 11 f 4 m; 7 f 2 m; 8 fN. acute events 2.9±0.8 3.3±0.6 3.4±0.5 3.5±0.5SF36-PCS 39.1 (10.3) 41.2 (9.2) 46.1 (12.0) 40.4 (6.2)SF36-MCS 47.1 (14.6) 42.7 (15.3) 50.3 (7.3) 26.8 (18.9)WI 4 (2) 3 (3) 1 (1) 4 (1)ODI 24 (42) 28 (18) 12 (13) 34 (10)VAS 6 (4) 7 (2) 7 (2) 8 (1)

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 CG

PCS MCS PCS MCS

NES ES NES ES NES ES NES ES

Median value (inter-quartile range)

Baseline 39.1 (10.3) 41.2(9.2)

47.1(14.6) 42.7 (15.3) 46.1

(12.0)40.4(6.2)

50.3(7.3)

26.8(18.9)

End of treatment 42.3 (9.6) 41.1(9.0)

50.6(17.0)

48.7(8.8)

46.6 (12.5)

40.0(5.1)

52.1(6.4)

28.4(19.6)

3 monthsf-up 45.3 (4.5) 45.9 (11.6) 48.5

(19.9) 49.3 (10.9) 42.8 (10.6)

41.1(7.4)

50.5 (10.7)

27.0(17.1)

6 monthsf-up 45.0 (8.8) 46.7 (13.1) 52.9

(7.7) 47.7 (11.4) 46.3 (11.5)

39.6(6.8)

48.9 (18.5)

28.6(23.7)

Analysis of Friedmanc2 21.27 13.80 6.80 10.33 0.41 0.94 2.24 3.03p <0.001 0.003 0.079 0.016 0.938 0.816 0.525 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 Friedman’s analysis for each subgroup (in bold if P<0.05).

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differences were not significant when the two BS-subgroups were compared (OSW: P=910; SF36-MCS: 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

The median values and inter-quartile ranges recorded for the physical and mental composite scores of SF-36 were reported in Table II. Ana-lysing the SF36-PCS and SF36-MCS by means of Friedman’s analyses, on each sub-group of sub-jects, significant improvements across time were recorded only for the two BS-subgroups, but not for the control subgroups (Table II). The differ-ences 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 SF36-PCS 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 peri-od, it slightly decreased in BSG-ES, and it increased only during follow-up.

A reduction of SF36-MCS at six-month follow-up 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-

in CG were excluded from the study because they had not a sufficient number of answers to the MM-PI-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

Baseline assessment

At baseline, 29 out of the 50 participants (58%) re-sulted with an elevation in at least one scale of MM-PI-II. One elevation was noted in 13 subjects (26%, 9 of them with hypochondria), and two or more el-evations in 16 subjects (32%, with hypochondria, de-pression, 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 dif-ferences for age among the four subgroups (χ2=1.23, P=0.746).

At baseline, also the scores recorded for par-ticipants included into BS-treatment were not sig-nificantly different from those recorded for control group (CG) in terms of SF36-PCS (P=0.191), SF36-MCS (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

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).

50

40

45

35Baseline End of

treatment3 monthsfollow-up

6 monthsfollow-up

Phys

ical

com

posi

te s

core

NESES

50

40

45

35Baseline End of

treatment3 monthsfollow-up

6 monthsfollow-up

Men

tal c

ompo

site

sco

re

NESES

A B

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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 meas-ures analysis of variance performed on all partici-pants. Time and interaction between time and treat-ment resulted the factors that significantly affected SF36-PCS, whereas SF36-MCS was affected by eleva-tions in MMPI-II scale (ES vs. NES), and by the in-teractions between time and treatment and between treatment and elevations (Table IV).

Secondary outcome measures: disability and pain

Highly significant improvements were also ob-served in terms of WI, ODI, and VAS for BSG-NES (P≤0.001, Figure 3 and Table III). The improvements for BSG-ES were highly significant in terms of ODI and VAS (P≤0.001) and significant in terms of WI (P<0.05).

Table III.—� Improvement in domains of quality of life and re-duction in disability and pain.

Friedman’s analysis (c2, P) BSG-NES BSG-ES CG-NES CG-ES

PF 17.81<0.001

9.160.027

0.810.846

3.720.293

RP 5.120.163

9.530.023

0.790.852

1.500.682

BP 17.420.001

22.21<0.001

5.830.120

1.470.689

GH 12.170.007

9.960.019

5.070.166

5.850.119

VT 10.470.015

21.98<0.001

5.080.166

2.040.564

SF 0.750.861

4.400.222

4.200.241

4.050.256

RE 5.870.118

14.430.002

2.500.475

4.450.216

ME 4.810.186

9.060.029

1.030.794

0.710.871

Waddel Index 20.4<0.001

12.320.006

0.690.875

1.320.724

Oswestry Disability Index 15.640.001

18.28<0.001

2.280.516

3.070.381

Pain Visual Analogue Scale 23.17<0.001

23.40<0.001

1.350.716

3.170.366

Results of Friedman’s 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: Vital-ity; 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.

Table IV.—�Factors affecting quality of life.

Repeated measures anovaPCS MCS

F P F P

Time 6.82 <0.001 1.70 0.170Treatment 0.01 0.943 2.73 0.105Elevations on scale 0.50 0.484 6.49 0.014Time*Treatment 6.59 <0.001 4.20 0.007Treatment*Elevations 0.74 0.394 5.04 0.030Time* Elevations 1.21 0.309 1.05 0.374Time*Treatment*Elevations 0.77 0.513 0.94 0.426

Results of repeated measures analysis of variance (in bold if P<0.05) per-formed 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.

5

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2025

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8

6

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Baseline Endof treatment

3 monthsfollow-up

6 monthsfollow-up

Figure 3.—Secondary outcome measures. From top to below: Os-westry Disability Index, Waddel Disability Index, Pain Visual Ana-logue Scale for subjects with NES (black) and ES (grey).

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Discussion

The main purpose of this study was to investigate if the rehabilitation outcomes of a Back School treat-ment 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, independ-ently by the presence or not of an elevation in MM-PI-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 MMPI-II 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 treat-ment in people with one or more elevations, in par-ticular 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 medi-cal treatment was less effective in patients with psy-chological 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 as-sessment did not lead to poor outcomes. It is note-worthy 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 cogni-tive-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 ac-cordance with some other studies.5, 23 This highlights

the importance of an adequate rehabilitation program carried out by a multidisciplinary team, that may pro-vide 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 dis-ability 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 sen-sation 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 fol-low-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 exact-ly measure anxiety, fear/avoidance and depression (psychological factors already shown as correlated with low back pain) and the absence of a progres-sive 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 ed-ucational exercises, such as Back School Program, similarly to other patients in terms of physical im-provement and even more in terms of mental im-provement.

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

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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