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Lumbar strengthening in chronic low back pain patients

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Title:
Lumbar strengthening in chronic low back pain patients psychological and physiological benefits
Creator:
Risch, Sherry V., 1953-
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English
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viii, 109 leaves : ; 29 cm.

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Subjects / Keywords:
Anxiety ( jstor )
Chronic pain ( jstor )
Control groups ( jstor )
Exercise ( jstor )
Human back ( jstor )
Low back pain ( jstor )
Pain ( jstor )
Psychology ( jstor )
Psychometrics ( jstor )
Social psychology ( jstor )
Back Pain -- therapy ( mesh )
Exercise Therapy ( mesh )
Lumbosacral Region ( mesh )
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bibliography ( marcgt )
theses ( marcgt )
non-fiction ( marcgt )

Notes

Thesis:
Thesis (Ph. D.)--University of Florida, 1990.
Bibliography:
Includes bibliographical references (leaves 89-97).
General Note:
Typescript.
General Note:
Vita.
Statement of Responsibility:
by Sherry V. Risch.

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University of Florida
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University of Florida
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Copyright [name of dissertation author]. Permission granted to the University of Florida to digitize, archive and distribute this item for non-profit research and educational purposes. Any reuse of this item in excess of fair use or other copyright exemptions requires permission of the copyright holder.
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22534541 ( OCLC )
ocm22534541
001523237 ( ALEPH )
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LUMBAR STRENGTHENING IN CHRONIC LOW BACK PAIN PATIENTS:
PSYCHOLOGICAL AND PHYSIOLOGICAL BENEFITS















BY

SHERRY V. RISCH















A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL
OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE OF
DOCTOR OF PHILOSOPHY

UNIVERSITY OF FLORIDA


1990















This dissertation is dedicated to my husband, E. David

Risch, and my two children, Valerie and Kristopher, who have

encouraged and supported my efforts over the years. Their

faith and understanding will always be cherished.















ACKNOWLEDGEMENTS

I wish to express my appreciation and thanks to my

chairperson, Nancy Norvell, for working with me on this

study and affording me the opportunity to complete it under

her supervision. Most importantly, I appreciate her

continued support and her contributions of advice and

expertise in this study's formulation and completion. In

addition, a special thanks are extended to my committee

members, Michael Robinson, Anthony Greene, James Johnson,

and Michael Pollock, for their support and supervision in

this dissertation preparation. I also extend my thanks and

gratitude to the staff of E. David Risch and to the staff of

the Center for Exercise Science for their assistance in the

completion of this treatment study. Mostly, a special

thanks are extended to my husband and children for their

support and understanding while I worked on this

dissertation. Without their love and reassurance, I could

not have persevered in completing this work.


iii
















TABLE OF CONTENTS


Page

ACKNOWLEDGEMENTS.................................... iii

LIST OF TABLES..................................... vi

ABSTRACT.................. ..... ..... ............. vii

CHAPTERS
1 INTRODUCTION.............................. 1

Chronic versus Acute Pain................. 2
Treatment of Chronic Pain................. 9
Self-Efficacy and Decreased Avoidance of
Physical Activities..................... 20
Physical Reconditioning as a Way of
Improving Muscular Strength and
Psychological Symptoms.................. 28
General Effects of Exercise on
Psychological Functioning............ 30
Exercise in Chronic Low Back Pain
Patients............................. 33
Exercise of the Low Back.................. 35
Hypotheses............................... 40

2 METHOD................................... .. 43

Subjects................................... 43
Equipment and Measures.................... 44
MedX Assessment and Training ........... 44
Self-Report Questionnaires............. 45
Procedures ............................... 51
Experimental Group..................... 52
Wait-List Control Group................ 52
Statistical Analysis................... 53

3 RESULTS.................................... 56

Physiological Results..................... 58
Psychological Results..................... 59
















4 DISCUSSION ...... ......................... 70

Physiological Findings.................... 72
Psychological Findings.................... 74
Implications............... ....... ....... 80
Limitations of the Study.................. 84
Conclusions and Future Directions......... 87

REFERENCES......................................... 89

APPENDICES..................................... .... 98

A PAIN QUESTIONNAIRE....................... 98

B POST TREATMENT PATIENT QUESTIONNAIRE...... 105

BIOGRAPHICAL SKETCH................................ 109
















LIST OF TABLES


TABLE PAGE

TABLE I SUBJECT CHARACTERISTICS OF THE
WAIT-LIST CONTROL AND TREATMENT
GROUPS STUDIED FOR EFFECTS OF
EXERCISE OF THE LOW BACK MUSCLES..... 57

TABLE II PHYSIOLOGICAL MEASURES................ 62

TABLE III PSYCHOLOGICAL DYSFUNCTION AND PAIN
PRE/POST-TREATMENT MEANS AND
STANDARD DEVIATIONS................... 64

TABLE IV MULTIPLE REGRESSION OF THE RELATIONSHIP
OF PRE-TREATMENT PSYCHOLOGICAL
VARIABLES TO POST-TREATMENT INTERCEPT
VALUES............ ................... 68

TABLE V CORRELATION ANALYSIS OF STRENGTH CHANGES
(CHANGES IN INTERCEPT SCORES PRE/POST-
TREATMENT) AND POST-TREATMENT
PSYCHOLOGICAL MEASURES................ 69









Abstract of Dissertation Presented to the Graduate School
of the University of Florida in Partial Fulfillment of the
Requirements for the Degree of Doctor of Philosophy

LUMBAR STRENGTHENING IN CHRONIC LOW BACK PAIN PATIENTS
PSYCHOLOGICAL AND PHYSIOLOGICAL BENEFITS

By

Sherry V. Risch

May 1990

Chairman: Nancy K. Norvell, Ph.D.
Major Department: Clinical and Health Psychology

This study examined the effects of dynamic exercise on

the isometric strength of the lumbar extensors in a chronic

low back pain population. It was hypothesized that exercise

on the MedXTM machine would result in increased lumbar

strength which would be associated with decreases in pain

and physical and psychosocial impairments.

Fifty-five chronic low back pain subjects participated

in the study. Thirty-one patients were randomly assigned to

a treatment group and 23 patients were assigned to a wait-

list control group. Prior to participating in the study,

all subjects were tested on the MedXTM machine for isometric

strength and were administered psychological questionnaires

addressing physical and psychosocial dysfunction, pain,

stress, depression, and anxiety.

Treatment consisted of variable resistance dynamic

exercises two times each week for six weeks, followed by one

session each week for six weeks. The control group was

requested to make no changes in their current life-style or


vii









methods of treating their pain. All subjects were re-tested

on the psychological questionnaires and re-tested for

isometric strength on the MedXT at the end of 12 weeks.

Multivariate analysis of covariance of change scores

revealed that the treatment group significantly improved in

strength as compared to the control group. Increased

strength was associated with a significant decrease in pain

and in physical and psychosocial dysfunction. In contrast,

the control group increased in reported pain and perceived

physical and psychosocial dysfunction. There were no

significant differences between groups on measures of

depression, anxiety, and stress.

Pre-treatment measures indicated that both groups

reported high levels of self-efficacy (internal locus of

control) prior to entering the treatment protocol, but post-

treatment analysis indicated that the control group changed

to decreased self-efficacy expectations (an external locus

of control). The treatment group maintained a high self-

efficacy rating post-treatment.

The findings of this study support the hypothesis that

exercise on the MedXTM machine is a beneficial treatment for

chronic low back pain patients. There is evidence that

increasing the strength of the low back muscles decreases

pain and improves physical and psychosocial functioning.

Self-efficacy expectations were significantly related to

treatment gains.


viii















CHAPTER 1
INTRODUCTION


The importance of rehabilitating patients with low back

pain is evident from reports which estimate that 80% of the

general population and 85% of the industrial population will

at some time experience low back pain (Feuerstein, Papciak,

& Hoon, 1987; Mayer, Gatchel, Kishino et al., 1986;

Rosomoff, 1985; Schuchmann, 1988). More specifically, this

disabling condition has partially disabled five million

people in the United States and accounts for approximately

93 million lost work days resulting in a sixteen billion

dollar economic loss each year (Block, 1982; Snook &

Webster, 1987).

Low back pain is commonly associated with injuries of

the nerves, bone, joint or ligaments, with resulting

myofacial syndromes and degenerative diseases of the spine

(Feuerstein et al., 1987). Of note, a high percent of the

patients with low back pain appear to suffer from soft

tissue injury in the lumbar spine area, with 78% of disabled

low back pain patients having no demonstrable

pathophysiological basis for their pain (Bono & Zasa, 1988;

Loeser, 1980; Mayer et al., 1986). Thus, treatment of the










low back pain patient focuses not only on spinal

abnormalities but also on the surrounding soft tissue areas.

Chronic versus Acute Pain

The experience of pain is described as acute or

chronic. Acute pain is often defined as a neural response

to a perceptual experience caused by a noxious stimulus.

This experience then leads to suffering and negative

affective states. These pain-eliciting states are

interpreted by the individual as signals of a problem that

requires intervention (Bono & Zasa, 1988). Hence, the

experience of acute pain is believed to be correlated with a

physiological process and the associated pain subsides when

the symptoms are resolved.

Chronic pain is different from acute pain because the

symptoms are present and persistent for an extended period

of time. Chronic pain has been arbitrarily differentiated

from acute pain by establishing a time frame of

approximately six months. This time criteria was derived

from research by Sternbach (1974) which found personality

differences between patients who suffered pain for less than

six months compared to those who suffered for more than six

months. Patients who suffered longer durations of pain were

noted to have higher elevations on the clinical scales of

the Minnesota Multiphasic Personality Inventory (MMPI),

suggesting increasing psychological distress with increasing

durations of pain.










Chronic pain patients have been described as being

poorly psychologically adjusted. As the chronicity of pain

exceeds six months, these individuals evidence behavioral

changes (i.e., restricted activities), emotional distress

(i.e., anxiety or depression), heavy medication usage, and

increased reliance on the health care system. These factors

as well as many others are often explained in the literature

as a result of increased psychological distress created by

the patients' long-term disabilities in relation to their

psychosocial and economical environments (Bono & Zasa, 1988;

Urban, 1982). For example, Ackerman and Stevens (1989)

studied 110 patients presenting for treatment of acute and

chronic pain. These authors found that both groups

experienced increased levels of state anxiety, but the

chronic pain group was significantly differentiated from the

acute pain group in their experience of a negative affective

state (e.g., depression) which was again believed to be

associated with the chronicity of pain.

Bono and Zasa (1988) further differentiated the chronic

pain experience according to the individual's adjustment and

reaction to his/her pain. These authors reported that not

all chronic pain patients fail to adapt to their

difficulties and some continue to function well in society.

They identified patients with "chronic pain" as those who

are without deleterious psychosocial/environmental










disruptions, and those patients who are dysfunctional, as

exhibiting a "chronic pain syndrome."

The chronic pain syndrome has been associated with

western medicine and industrialized civilizations. Waddell

(1987) commented that prior to modern medicine and

industrialization, the prevalence and incidence of back pain

was the same as it is now, but those individuals did not

stop daily activities or become permanently disabled. He

postulated that seeking health care for chronic pain is a

function of the individual's perception and interpretation

of physical symptoms and a function of the availability and

expectations of medical treatment. Hence, the chronic pain

syndrome has been associated with psychological distress,

depression, the experience of failed treatment

interventions, and a sick role adaptation; not as a response

to physiological activity.

There are many theories that attempt to describe and

define the chronic pain experience. The original theories

of pain were based on a somatosensory model. This model

postulated that feelings of pain were directly proportional

to peripheral damage (Blackwell, Galbraith, & Dahl, 1984;

Tursky, Jamner, & Friedman, 1982). However, current

theories of pain disagree with this model. More recent

theories propose that the subjective feeling of pain is not

directly related to tissue damage, but instead, results from

an interaction of physical, socio-environmental, and











psychological experiences (Bandura, O'Leary, Taylor,

Gauthier, & Gossard, 1987; Craig, 1983; Turk, Meichenbaum, &

Genest, 1983; Weisenberg, 1977).

An often-cited theory of pain is Melzack and Wall's

(1965) Gate Control Theory. This theory postulates a

neurophysiological basis for the role of psychological

factors in the pain experience. It describes the

interaction between sensory-discriminative, affective-

motivational, and cognitive-evaluative systems (Turk & Flor,

1984; Turskey et al., 1982; Melzack & Dennis, 1978). The

model incorporates the importance of psychological factors

in the central nervous system's modulation of pain. The

perception of pain is said to be influenced by the

individual's attitudes and attentions which act through a

central control mechanism. The control mechanism operates

via descending neural fibers which modulate the excitation

of afferent pain receptors in the dorsal horn of the spinal

column. Opening and closing of this control mechanism

increases or decreases sensory sensitivity. In summary,

suffering with pain is correlated with psychological states

that exacerbate the neurophysiological mechanisms (Clark &

Yang, 1983; Melzack & Dennis, 1978; Turk & Flor, 1984;

Tursky et al., 1982).

In support of this model of pain, experimental studies

have shown that reported pain severity and reactions to pain

are related to cultural variables (Sternbach & Tursky,










1965), to the influence of social modeling (Craig, Best, &

Ward, 1975), to the mood states of the patient (Clark, 1974;

Turk & Kerns, 1984), to previous learning and medical

management (Fordyce, 1988), and to a physiological

hyperactivity (Flor & Turk, 1989).

For example, Sternbach and Tursky (1965) interviewed 60

subjects from four different ethnic backgrounds and obtained

information regarding the subject's past reactions and

perceptions to pain. Subjects then participated in a

laboratory experiment which tested pain thresholds,

estimated stimulus intensities, and autonomic reactivity.

Findings of this study indicated that different subcultural

groups hold different attitudes (e.g., "pain is to be

suffered in silence" versus "fear the worst") about pain and

that based on these attitudes, they experience pain

differentially.

Another experimental study by Craig et al. (1975)

exposed 30 undergraduate students to various levels of

shock. This study found that subjects differed in their

reported experience of pain as a function of being exposed

to a pain-tolerant model versus a pain-intolerant model.

Subjects exposed to a pain-intolerant model reported more

pain. Hence, this study lends support not only for the

cognitive-mediation in the experience of pain, but also in

the influential role of social-environmental mediators.









7

Several studies have found that psychological variables

are frequently associated with reports of pain, especially

depression and anxiety. Not only do clinically depressed

patients frequently report pain symptoms, but pain patients

frequently report depressive symptoms (Weisenberg, 1977).

For example, a study comparing 33 chronic low back pain

patients to 35 healthy controls found that depression and

anxiety were commonly reported in the low back pain group,

not in the control group. It was further noted that the

severity of depression and anxiety were positively

correlated with increased pain reports (Feuerstein, Sult, &

Houle, 1985). The role of anxiety in pain is further noted

in Weisenberg's (1977) statement that patients who trust

their physicians reduce their presenting anxiety and this

leads to decreased pain reports and increased responsiveness

to placebo treatments. For example, laboratory studies

utilizing psychological procedures such as attention

diversion, cognitive restructuring, and hypnotic inductions

have been found to significantly reduce anxiety and

subsequently the experience of pain (Bandura et al., 1987;

Spanos, Perlini, & Robertson, 1989), Additionally,

psychological measures of depression and anxiety decrease

significantly with decreased pain after treatment (Gatchel,

Mayer, Capra, Diamond, & Barnett, 1986).

There are other theories and models attempting to

explain the experience of chronic pain. For example,










researchers have studied pain with psychophysical

definitions of pain threshold levels, with intensity

ratings, with magnitude estimations (utilizing cross

modality matching scales for intensity and quality of pain),

and with observable behaviors for discrimination and

detection of pain (Chapman, Casey, Dubner, Foley, Gracely &

Reading, 1985). Additionally, chronic pain has been

described as a psychobiological disorder; as a symptom in

which pain fulfills the needs of a dysfunctional family

system; as a classical conditioning paradigm or respondent

model of pain in which a pain-tension cycle is created; as

an operant model where the pain is believed to be under the

control of contingencies of reinforcement; and finally, as a

diathesis stress model where physical, psychological and

social factors are believed to have preconditioned the

patient for hyper-reactivity with a responsive stereotypic

style diathesiss) resulting from a genetic predisposition

(Chaturvedi, Varma & Malhotra, 1984; Turk & Kerns 1984).

Theories of pain sensation and sensitivity are

beneficial in explaining the nociception of experimentally

induced pain, but they fall short in describing the clinical

patient presenting with the chronic pain syndrome.

Laboratory studies have successfully documented the role of

endogenous opioids and cognitive mediational processes in

the control of pain (Bandura et al., 1987; Yang, Richlin,

Brand, Wagner, & Clark, 1985), but as mentioned earlier,











there is a lack of understanding between chronic pain and

the chronic pain syndrome (Bigos & Battie, 1987). Hence,

theories of pain that incorporate psychological, physical,

and environmental influences are more proficient at

explaining the chronic pain experience.

In summary, there are many models and explanations of

acute and chronic pain experience, most of which include

psychological and social phenomena as a prominent factor.

Therefore, a biopsychosocial conceptualization of chronic

pain (which incorporates the role of physiological,

social/environmental, and psychological responses) is viewed

as the predominant working model (Waddell, 1987).

Treatment of Chronic Pain

Interventions and treatment of the chronic pain patient

vary depending on the practitioner's theoretical formulation

of the chronic pain syndrome. Traditionally, medical

treatments have consisted of conservative management which

included bed rest, traction and medication, or surgical

interventions. Unfortunately, these treatment modalities do

not appear to resolve the pain for a significant majority of

chronic pain patients. For example, short-term pain relief

often follows surgery, but for some patients, surgery does

not provide long-term pain relief. Gottlieb et al. (1977)

cited unpublished data by Shealy and Beckner (1975) stating

that 30% of the patients undergoing a traditional

neurosurgical procedure failed to experience post-operative









10

pain relief and at the end of five years, 90% of the surgery

patients failed to experience satisfactory pain relief. In

a study of conservative medical treatment, Finneson (1973)

reported findings that only 50% of the population studied

reported significant pain relief with conservative treatment

after three years. Thus, it was concluded that traditional

medical treatments did not exceed a 50% success rate and,

therefore, treatment successes could not be distinguished

from spontaneous remission rates.

Fordyce (1988) reported a prospective study of acute

low back pain patients in which he addressed differential

treatment recommendations as they effected long-term

outcome. Patients presenting to a hospital emergency room

with acute low back pain were randomly assigned to one of

two groups. The first group (Group A) received open ended

instructions such as to take medication as their pain

dictated, to exercise when their pain subsided or as

tolerated, and to remain in bed for an unspecified time. In

contrast, the second group (Group B) was instructed to take

medication at a fixed time interval and for a specified

duration, to remain in bed for only a specific period of

time, and to exercise according to a pre-set regimen. At

six weeks follow-up, there were no differences between the

groups, but at 9 to 12 months follow-up there were

significant differences found. Group A (open-ended

instructions) was found to report more physical impairments,









11

disrupted vocational status, increased levels of health care

utilization, and higher levels of pain. The conclusions

drawn from this study were that subjects with vague open-

ended guidelines for treatment experienced increased pain

from muscular disuse and then potentially interpreted their

pain as a failed healing process. These findings are of

particular import in that they document the role of

expectancy in the efficacious treatment of acute pain and

its relationship to the later development of chronic pain.

This is consistent with Waddell's (1987) contention that

physical illness, illness behavior and psychological

distress combine to produce disability. Bigos and Battie

(1987) reached a similar conclusion stating that there is an

important difference between treating back pain and

preventing chronic back pain disability. Hence, the

interaction between physical illness, pain behaviors and

psychological states may determine the outcome of treatment

of acute pain, while continued disability, work loss, and

failure to return to work may be more related to social

factors than physical disease (Waddell, 1987).

In order to better address and treat the chronic pain

phenomenon, many treatment interventions focus on

psychological variables associated with chronic pain. In

addition to the subjective experience of pain, chronic pain

patients frequently report psychological distress, including

symptoms of anxiety and depression. Thus, as Gottlieb et









12

al. (1977) state, the patient's distress may be as important

as any structural damage in treating the chronic pain

patient. Treatments with a physical-psychological focus

often use operant conditioning principles that attempt to

extinguish pain behaviors by reinforcing "well behavior" and

ignoring "sick behavior." Within this treatment protocol,

there is a strong emphasis on increasing the patient's

physical activities (well behavior) and helping the patient

develop coping strategies which will lead to reductions in

sick behaviors (Block, 1982; Keefe & Gil, 1986; Turk, Wack,

& Kerns, 1985). This treatment approach endorses the notion

that chronic pain behaviors potentially come under the

control of environmental contingencies. For example, if

pain is experienced following the lifting of a heavy object,

avoiding lifting that object will decrease the pain

(respondent conditioning). With the continued avoidance of

lifting the heavy object, the behavioral changes become

operant in nature and may generalize to lifting all objects

or even to the entire work place. A reinforcement

contingency then develops in the absence of the original

pain-eliciting event. Hence, the individual generalizes

pain behaviors to other situations. A secondary

reinforcement contingency may also develop from potential

positive reinforcement received by others deriving from

their changed pain behavior patterns operantt conditioning)

(Bono & Zasa, 1988). The operant treatment approach,









13

therefore, attempts to extinguish pain behaviors by changing

the contingencies of reinforcement to well behaviors.

Specific goals of these physical-psychological

treatments are to reduce pain behaviors such as medication

use, inactivity, and verbal and nonverbal pain

communications (such as guarding and bracing). Medication

reduction is often achieved by administering "pain

cocktails" or by reinforcing patients in their own attempts

at reducing medication utilization. Low activity levels are

usually assessed by self-report measures of "up-time" (time

that the patient is not in a reclined position). Some

studies report more objective measures of assessment such as

video taping while the patient engages in various activities

(e.g., sitting, standing, and walking). Treatment

interventions for activity levels most often include

reinforcement for up-time. Patients are encouraged to

gradually increase their time out of bed, walking, and doing

various activities. Patients' perceived ability to perform

increased activity levels are also encouraged and reinforced

through their participation in general physical therapy

modalities. Treatment for verbal and nonverbal pain

behavior is usually accomplished by ignoring inappropriate

behaviors (body postures or verbal complaints) and

reinforcing appropriate behaviors. Hence, the physical

component to these treatment programs relies heavily on the

psychological concept of operant conditioning.










Psychological interventions usually include cognitive-

behavioral techniques. For example, Fordyce (1976) proposes

that pain behaviors are maintained by contingent events and

thus are amenable to behavioral interventions such as

undesirable consequences for certain pain behaviors.

Similarly, within this behavioral framework, increases in

activity levels are encouraged and rewarded. Since social

factors have been found to have a significant impact on the

chronic pain experience, many psychological interventions

include family therapy to address the role of positive and

negative social reinforcement from significant others.

Patients are often instructed in relaxation and biofeedback

techniques, and various coping strategies are taught (such

as pacing daily activities). In terms of more cognitive

interventions, faulty cognitions are challenged. This

teaches the patient to identify and relabel negative and

defeating self-statements, which leads to more adaptive

functioning. Psychological interventions are also

accomplished with individual psychotherapy or group therapy

sessions. These psychological interventions focus on faulty

cognitions, affective reactions, and ineffective coping

strategies, while at the same time they encouraged the

patient to increase his/her physical activities. Hence, the

psychological component of these programs is heavily laden

with a physical component--increased activity (Block, 1982).









15

Many treatment programs emphasize a multimodal approach

to the treatment of chronic pain. These treatment protocols

include psychological, physical, and vocational

interventions. Such multidisciplinary interventions appear

to produce significant improvement in chronic pain patients.

In a review of multimodal treatment studies which included

follow-up, Block (1982) found that studies including a 10-

month follow-up reported an average of 58% of the subjects

had reduced their intake of analgesic medications. Other

improvements include 75% either employed or in employment

training programs, 70% with significantly increased activity

levels, and 74% received no additional treatment. Block

(1982) also reports that in studies with 3-year follow-up,

an average of 60% of the subjects had reduced their

analgesic medications, and 100% maintained increased

activity levels.

Although Block's (1982) review suggests that these

treatment programs are successful, the studies reviewed

provide only limited information in that they were quasi-

experimental. Additionally, patients participating in

multidisciplinary pain treatment centers are a select sample

and only represent a small percentage of individuals

suffering with chronic low back pain. Participation in

these multidisciplinary programs usually requires

authorization and payment by insurance companies (mostly

workmen's compensation) and is often contingent on the










patient receiving a final disability determination at the

end of treatment. Differences in treatment responsivity and

sample characteristics in different treatment settings were

documented in a study by Deyo, Bass, Walsh, Schoenfeld and

Ramamurthy (1988). These investigators recruited subjects

for a clinical treatment of low back pain by advertising for

an outpatient treatment program (clinical group), and they

recruited another sample of subjects with low back pain in a

multidisciplinary pain clinic. Although the two groups of

subjects did not differ on duration or intensity of pain,

there were significant differences found between the groups

pre- and post-treatment. The clinical outpatient group was

more likely to be working, using no medication, having

higher incomes and education, and not receiving workmen's

compensation pre-treatment. Additionally, post-treatment

findings indicated that the clinical group significantly

benefited more from treatment compared to the

multidisciplinary treatment group. Hence, the authors

suggested that patients participating in multidisciplinary

treatment programs tend to represent a small, specific

sample who experience not only chronic pain, but have lower

incomes and education and are more reliant on insurance and

work related compensations which impacts on treatment

outcome (Deyo et al., 1988).

Another problem in this area of research is that few

experimental studies have been conducted which examine the











specific physical or psychological effects of a

comprehensive treatment program. Philips (1987) reported a

cognitive-behavioral treatment program that utilized random

assignment to a wait-list control or treatment group. He

found that 83% of the subjects in the treatment group

improved relative to the control group. Treatment consisted

of teaching the patients techniques to manage and control

their pain and techniques to increase their exercise levels

and physical fitness. Hence, improvement was described as

increased physical fitness levels and decreased

psychological distress (Philips, 1987).

In a study by Heinrich, Cohen, Naliboff, Collins and

Bonebakker (1985), chronic pain patients were assigned to a

physical therapy treatment or to a behavior therapy program.

Both treatments addressed increasing activity levels. They

found that both groups improved after treatment, and

interestingly, there were no significant differences between

the two groups at 6- and 12-month follow-ups.

Studies addressing physical reconditioning and

cognitive behavioral treatments in multimodal treatment

programs report significant improvements after treatment and

at long-term follow-up. Improvements typically are defined

as return to work or in training programs, decreased

psychological dysfunction, and increased physical

functioning. Subjects participating in these studies are

considered to be refractory to previous medical treatments










and are not candidates for surgical interventions.

Treatment success is high in these studies, but it should be

noted that insurance companies pay for these programs and

they expect their clients to return to work or receive final

disability at completion. Hence, it is not surprising that

subjective measures of experienced pain are not considered

predictive of a successful outcome, but instead, return to

work is the measure of successful outcome. Additionally,

there is a selection bias inherent in these studies due to

the fact that some insurance companies refuse to pay and

some subjects refuse to participate due to the knowledge of

a potential risk to their economic situations (Gatchel et

al., 1986; Mayer, Gatchel, Mayer, Kishino, Keeley, & Mooney,

1987; Mayer et al., 1986; Mayer, Smith, Keeley, & Mooney,

1985; Mayer, Gatchel, Kishino, Keeley, Capra, Mayer,

Barnett, & Mooney, 1985).

Given that chronic pain patients suffer differentially

with physiological symptoms, psychological distress, and

environmental disruption, it is important to understand the

components of multimodal treatment programs that are

beneficial. Since treatment success is often defined as

increased functional activity (Gottlieb et al., 1977), it is

reasonable to assume that the effective ingredient might be

the physical reconditioning component. On the other hand,

improved psychological well-being may lead to improved

functioning and increased activity (Weisenberg, 1987).










Therefore, in order to better understand the effects of

these treatment programs, there is a need for studies to be

conducted within an experimental design (Tan, 1982).

Recent studies contend that the important element in

the treatment of chronic low back pain patients is increased

functional strength. Quantitative strength changes and

physical improvement have been postulated to be important

for surgical decisions, designing rehabilitation techniques,

and for disability determinations (Mayer et al., 1985).

Furthermore, treatment programs that offer passive treatment

modalities (i.e., spinal manipulation, electrical

stimulation, and biofeedback) potentially increase a

patient's dependence on the health care system and

potentiate their manifestation of the sick role. Given the

complexity of these multidisciplinary treatment programs,

evaluation of successful treatment is difficult in that it

incorporates medical, legal, psychological, and

socioeconomic problems. One of the most current assertions

is that the major deficit in chronic low back pain is a

physical deficit from muscular disuse caused by prolonged

and excessive protection of the spine (Mayer et al., 1987).

Hence, there is a strong need for future research to address

the relative importance of the various therapeutic elements

(i.e., physical and psychological therapies) offered in the

multidisciplinary treatment programs (Hazard, Fenwick,

Kalish, Redmond, Reeves, Reid, & Frymoyer, 1989; Mayer et











al., 1985). In summary, the impact of improved physical

conditioning on functional abilities as well as

psychological status has not been sufficiently examined in

chronic low back pain patients.

Self-Efficacy and Decreased Avoidance of Physical Activities

Dolce (1987) postulated that the chronic pain patient's

desire to avoid pain results in more severe limitations in

activity than do actual physical limitations. This

avoidance of physical activity is similar to the behaviors

seen in phobic patients. A chronic pain patient fears

certain activities because an earlier activity was

experienced as aversive which created pain, tension and

anxiety. Hence, the patient continues to avoid activities

perceived as similar to the initial anxiety/pain-inducing

situation. The avoidance behavior is then reinforced by the

fact that the patient avoids the experience of increased

pain (Philips, 1987).

Self-efficacy theory as proposed by Bandura (1982) is

useful in understanding the cognitive mediators involved in

the chronic pain patient's avoidance of physical activity.

Self-efficacy is defined as an individual's belief in

his/her ability to perform a particular behavior. This

belief, in turn, can influence a certain outcome. For

example, Bandura (1982) suggests that thoughts about the

self mediate between knowledge of how to perform a behavior,

motivation to perform a behavior, and the actual performance










of a behavior. If the patient believes that he/she is

incapable of completing a certain behavior/activity, the

activity will be avoided. Self-efficacy beliefs will

determine not only the performance of an activity, but also

the amount of effort an individual will expend and persist

in an activity. In summary, the individual's belief that

he/she can master a certain behavior will predict actual

performance of a given behavior. If self-efficacy

expectations are negative, performance will be impaired in

spite of functional abilities (Dolce, 1987).

Bandura has shown that the phobic patient's perception

(self-efficacy expectancies) of his/her ability to cope with

and master in-vivo exposure to feared stimuli are predictive

of the patient's actual behavioral performance. He found

that with gradual exposure to a feared stimulus, the phobic

patient's prior self-efficacy expectations predicted his/her

performance of previously avoided behaviors, and that as

he/she performed these avoided behaviors, self-efficacy

expectancies increased.

Self-efficacy expectations have not only been shown to

predict behavioral change in phobia patients, but they have

also been predictive of behavioral change in other patient

populations. For example, Ewart, Taylor, Resse, and DeBusk

(1983) studied 40 males referred for treadmill exercise

following a myocardial infarction. Self-efficacy was

measured by a self-report questionnaire that asked the










patients to rate their self-perceived ability to perform

various activities (e.g., walking, running, and climbing

stairs). Self-efficacy was found to increase after

successful completion of treadmill exercise and was

predictive of the subject's participation in subsequent

activities such as walking, running, and climbing stairs.

Hence, enhanced self-efficacy expectations were

significantly correlated with the subject's actual intensity

and duration of subsequent physical activities. Along

similar lines, Manning and Wright (1983) found that self-

efficacy expectancies regarding an individual's perceived

ability to run a 10 Km race were more predictive of race

performance than the subject's actual running history.

Hence, the chronic pain patient's avoidance of physical

activity may not be in response to the experience of painful

sensations, but instead may be an avoidant coping mechanism

which is employed to reduce fear and anxiety associated with

activity.

Only a few studies have looked at the role of self-

efficacy expectations and the perception of pain. The role

of self-efficacy theory is important in that patients avoid

activities because pain signals a problem. Hence, the

patient develops avoidance behaviors independent of pain.

The impact of the patient's self-efficacy then is

determinant of their participation in treatment

interventions. For example, Kleinke & Spangle (1988) found











that patients exhibiting high levels of pain behavior and

reporting high levels of pain preferred to have an inactive

role in treatment (e.g., passive therapies such as ice or

heat packs) whereas patients with less pain behavior and

lower self-reported pain chose to take an active role in

their rehabilitation in the form of active physical

exercise.

Manning and Wright (1983) evaluated self-efficacy

expectancies (e.g., perceived ability to undergo childbirth

without the use of medication) in 52 pregnant women. Self-

efficacy expectations were found to predict persistence in

self-controlled pain during labor in that higher self-

efficacy ratings were correlated with decreased medication

usage. Of note, this finding was independent of the length

of time the subject experienced labor pain. These authors

concluded that self-efficacy expectations were a better

predictor of outcome (i.e., decreased pain complaints) than

were previously exhibited behaviors (e.g., behaviors during

child birth classes).

Holroyd, Penzien, Hursey et al. (1984) studied the role

of self-efficacy expectations in the control of tension

headaches. These authors recruited 43 recurrent tension

headache subjects from a college population for an

electromyography (EMG) biofeedback treatment study. This

study utilized a 2 x 2 factorial design in which subjects

were randomly assigned to one of four conditions. Treatment










conditions consisted of increased versus decreased EMG

activity feedback, and high versus moderate successful

control feedback. Findings of this study were that changes

in post-treatment headache activity were induced by

performance feedback and were not related to actual EMG

activity. In summary, whether the subjects were told that

they successfully increased or decreased EMG activity was

not significant in their subsequent reduction of headache

pain. Instead, the high success feedback significantly

decreased headache pain post-treatment regardless of the

direction of EMG activity. Hence, these authors proposed

that high success feedback increased the subject's self-

efficacy expectations which subsequently reduced their

headache pain.

Self-efficacy expectancies were evaluated in a study of

chronic pain patients involved in a nine week outpatient

treatment program (Philips, 1987). This treatment program

was done in a small group format and focused on teaching the

patients new coping strategies and on increasing their

activity levels. Self-efficacy ratings were taken for 40

consecutive subjects who presented for treatment of chronic

pain. Twenty five subjects were assigned to treatment

groups and 15 subjects were assigned to a wait-list control

group. Subjects completed questionnaires on their number of

avoidance behaviors and on their perception of the severity

of their pain problem. There were no differences between









25

the groups pre-treatment in avoidance behaviors or negative

perceptions, but at post-treatment there was a significant

difference. The treatment group reported significantly

higher levels of self-control over their pain (increased

self-efficacy) and perceived their pain as less of a problem

when compared to the wait-list control group. Hence, in

this study, learning coping strategies in therapy increased

their self-efficacy expectancies, enhanced their ability to

function, and decreased their negative perceptions of their

pain problem (Philips, 1987).

Dolce and colleagues (1986) reported several studies

addressing the role of setting quotas of performance,

feelings of mastery at different levels, and subsequent

self-efficacy ratings for future performance. They reported

a laboratory study in which 64 college undergraduates

participated in an experimental pain procedure (cold pressor

test). These subjects were asked to rate their self-

efficacy expectations on their ability to tolerate

increasing levels of pain. These investigators found that

setting systematic quotas for pain tolerance increased the

subject's ability to tolerate pain. In addition, there was

a significant correlation between self-efficacy expectancies

and actual pain tolerance. Of note, a group that took a

placebo medication supposedly to improve pain tolerance

actually decreased in pain tolerance. These authors

concluded that setting quotas was more beneficial than










rewards and reinforcement and that self-efficacy

expectations were significantly related to actual abilities

to tolerate pain (Dolce, Doleys, Raczynski, Lossie, Poole, &

Smith, 1986).

Another set of laboratory studies utilizing the cold

pressor test for pain stimuli reached similar conclusions.

Self-efficacy expectations in these studies were addressed

in conjunction with the role of cognitive mediation and

endogenous opioid involvement following pain stimulation.

Evidence of endogenous opioid mechanisms was found in

response to pain stimuli in addition to nonopioid cognitive

mechanisms. In these studies, a placebo medication group

increased their pain tolerance due to endogenous opioid

involvement, but did not increase their self-efficacy

ratings. In contrast, the cognitive strategy group

increased both their self-efficacy and pain tolerance.

Conclusions for the chronic pain patient based on these

laboratory findings were that strong self-efficacy may lead

to increased activities despite pain which potentially

exacerbates the pain and results in a cognitive loss of

control over the painful experience. Stress associated with

a sense of failing control with increasing pain then

activates endogenous opioid mechanisms for additional pain

control. Hence, it was noted that cognitive appraisals did

not effect the experience of pain, but instead increased the

subject's ability to endure pain which resulted in increased










emotional responses and subsequent opioid activation. It

was further concluded that self-efficacy is a causal

determinant of performance and is the moderating factor on

the subject's pain tolerance (Bandura et al., 1987; Litt,

1988; Taylor, 1989).

This line of research has also examined the role of

setting exercise quotas and subsequent self-efficacy ratings

in the clinical treatment of chronic pain patients. Two

articles were reviewed in which subjects were referred to a

pain-management clinic and assessment measures were taken

with respect to their actual ability to accomplish set

exercise quotas and their self-efficacy expectations. Self-

efficacy ratings were found to be predictive of actual

participation in physical exercise and in maintaining

physical activities post-treatment (Dolce, Crocker,

Moletteire & Doleys, 1986; Dolce, Crocker, & Doleys, 1986).

These studies suggest that chronic pain patients need

to be desensitized to their fear of activities, need to

develop a sense of mastery over their pain by actual

activity performance, need to develop the belief that the

demands of an aversive situation (exercise) are not greater

than their coping skills, and need to have an internal

attribution for treatment success. In addition, these

investigators found that the patient's past learning history

of successes and failures were often a primary determinant

of their self-efficacy ratings. In summary, self-efficacy









28
expectations are a useful predictor of pain coping behaviors

and of post-treatment maintenance of therapeutic gains

(Dolce et al., 1986a; Dolce et al., 1986b).

In conclusion, perceived control over a situation is

important when addressing the chronic pain patient's

motivation and ability to engage in exercise treatment

programs. Exercise is emphasized in the treatment of

chronic pain and is described as "well behavior". Efficacy

expectations are important considerations and effect how

much effort an individual will exert and how long they will

persist in the face of aversive experiences such as exercise

regimens or quotas that may initially exacerbate their

fears, anxieties, and pain.

Physical Reconditioning as a Way of Improving
Muscular Strength and Psychological Symptoms

Sedentary life styles and the lack of physical fitness

have been proposed as causal agents in maintaining low back

pain (Rosomoff, 1985). Not only do chronic low back pain

patients suffer with the nociception of their original pain,

but their pain experience is exacerbated by muscle atrophy

resulting from subsequent inactivity. Similarly,

psychological distress may not only be a consequence of low

back pain, but also has a role in the exacerbation of

existing pain levels (Flor & Turk, 1989: Gottlieb et al.,

1977). According to the Gate Control Theory of pain, stress

can lead to increased autonomic arousal and increased muscle

activity. This in turn leads to peripheral stimulation









29
(pain) and emotional reactions (such as stress and anxiety).

Hence, psychological distress may precipitate low back pain

by creating muscle tension in the weaker spinal muscles. If

these weaker, but tense muscles are subjected to a work-

load, the individual may then experience pain. Therefore, a

pain-stress cycle can begin with pain, or stress itself can

be a precipitating factor (Keefe & Gil, 1986; Linton, 1987).

Although the experimental findings on the relationship

between pain and stress with respect to chronic pain is

inconclusive, there is some evidence that individuals

manifest specific physiological responses to perceived

stress (Flor & Turk, 1989).

The pain-stress model suggests that psychological

distress can exacerbate pain in weaker muscle groups, and

that weak and painful muscles can exacerbate psychological

distress. Bortz (1984) suggested that "use" is a biological

principle inherent in all species and that inactivity

results in the muscles stiffening and decreasing in fiber

diameter which results in muscular atrophy. Hence, chronic

pain may be viewed as a "disuse syndrome". If muscular

atrophy and psychological distress contribute to the

experience of low back pain, treatment of the chronic low

back patient should address both areas. The studies

reviewed above share a focus on improving the chronic pain

patient's psychological and functional status by increasing

their activity levels. Hence, physical reconditioning with









30
exercise is a viable treatment modality with a chronic low

back pain population.

General Effects of Exercise on Psychological Functioning

In terms of psychological benefits, previous studies

suggest that physical exercise can decrease psychological

stress, anxiety, and depression in certain populations

(Dishman, 1985; Folkins & Sime, 1981; Keller & Seraganian,

1984; Levine, 1971; Reiter, 1981; Weisenberg, 1987). In

addition, physical fitness is proposed to enhance an

individual's ability to effectively manage emotional stress

and to improve adaptive interactions with the environment.

Improved cardiovascular functioning with exercise and

reduced resting muscle action potentials following exercise

are suggested to be associated with decreased tension and

psychological distress. Exercise is also purported to

provide an individual with a sense of mastery and control

which is then associated with feelings of psychological

well-being (Folkins & Sime, 1981).

However, there is inconsistency in the literature

regarding the specific psychological benefits of exercise,

and as Hughes (1984) suggests, many studies are quasi-

experimental and flawed with experimental biases. His

review of 12 studies which employed acceptable experimental

methodology, suggests inconclusive findings regarding the

effects of exercise on depression and anxiety. In keeping

with Hughes' (1984) review of a lack of consistent positive









31
findings for the psychological benefits of exercise, Hughes,

Casal, and Leon (1986) studied sedentary men assigned to an

exercise or a control condition. These authors found no

psychological benefits (such as reduced anger, depression,

or mood disturbance) derived from the exercise condition

when compared to controls. Another study confirmed these

findings with adult women. These women participated in an

exercise program and were compared to a no-exercise control

group. Again, no psychological benefits were found

(Coleman, Price & Washington, 1985).

In contrast, aerobic and anaerobic exercise have been

reported as beneficial in elevating mood states, improving

self-concept, and decreasing anxiety (Folkins & Sime, 1981;

Reiter, 1981; Sime, 1984). For example, Doyne Ossip-Klein,

Bowman et al. (1987) studied 40 depressed females and found

that both aerobic and anaerobic exercise significantly

decreased depression compared to a wait-list control group.

There were no differences found between the two types of

exercise, and treatment gains were maintained for both

groups at a one year follow-up.

These inconsistent findings suggest that the initial

level of psychological distress (anxiety, depression, or

self-esteem) is an important factor when exercise produces

psychological benefits. For example, low self-esteem

appears to improve following exercise, but the studies

looking at self-esteem only find changes if initial self-










esteem is very low (Hughes, 1984). Similarly, studies

looking at depression and anxiety find that mild to moderate

distress (as opposed to severe distress) can be modified by

exercise (Sinyor, Schwartz, Peronnet et al., 1983).

Dishman, Sallis, and Orenstein (1985) in their review

of the exercise literature found that as the severity of

psychological distress increased, there was a related

increase in withdrawal from exercise programs. These

authors conclude that continued participation in exercise

programs of all types was related to the individual's past

exercise history, perceived health, education, self-

motivation, and positive support from a spouse or

significant other. These conclusions are tentative at best

in that the literature they reviewed included diverse

populations and settings, various research traditions and

disciplines, and a variety of differing interpretations.

Although professionals and laymen alike, promote the

concept of "healthy body, healthy mind" (Sachs, 1982), most

of the research addressing this area is by anecdotal report,

or quasi-experimental designs. There are only a few studies

experimentally done which have investigated the

psychological benefits of exercise, and these have resulted

in conflicting results. These inconsistencies are

attributable to the lack of experimental designs, and to the

fact that many of the subjects had low levels of

psychological distress prior to treatment. In contrast, the










chronic low back pain patient is a unique population which

appears to experience significant psychological turmoil

(Gottlieb et al., 1977). Hence, the role of exercise may

have a more pronounced effect in this population. This

suggestion is consistent with the finding that treatment

programs that focus on increasing activity levels (well-

behavior) and decreasing sick behaviors (inactivity) have

been shown to be an effective treatment for chronic low back

pain patients (Block, 1982).

In summary, if exercise and physical reconditioning

does enhance an individual's ability to cope with stress,

and decreases anxiety and depressive symptomatology,

increasing the chronic low back pain patient's physical

activity through a structured exercise program should result

in his/her experiencing an improved psychological well-being

and decreased pain.

Exercise in Chronic Low Back Pain Patients

Studies addressing exercise in chronic low back pain

have found that exercise is beneficial in reducing pain and

increasing physical functioning (Bigos & Battie, 1987).

Exercise is reported as a major focus of treatment in 100%

of pain treatment clinics and in 86.8% of all patients with

reports of pain (Tollison, Kriegel, & Satterthwait, 1989),

but the beneficial role of exercise is not understood in the

treatment of chronic low back pain. For example, Jackson

and Brown (1983) state that the reasons for recommending










exercise include reducing pain, increasing strength,

decreasing mechanical stress on the spine, improving overall

physical fitness and preventing future injury, stabilizing

hypermobile spinal segments, improving posture, improving

mobility, and finally, recommending something "when all else

fails".

Although the role of exercise in chronic low back pain

is poorly understood, patients do improve following exercise

programs. For example, Manniche, Hesselsoe, Bentzen,

Christensen, and Lundberg (1988) reported significant

improvements in chronic back pain patients following two to

three months of exercise. Additionally, they found that

intensive exercise (multiple strengthening exercises for 1

1/2 hours for 30 sessions) was more effective than moderate

exercise (1/5 the intensity and time). In a large study of

the benefits of exercise conducted through the YMCA on

11,809 people, Kraus and Nagler (1983) reported on a

subsample of 546 post-surgical back pain patients that had

significant decreases in pain and increases in strength

following participation in a routine exercise program for

six weeks. Reilly, Lovejoy, Williams, and Roth (1989)

studied 40 males and females with chronic low back pain (10

each group) who were randomly assigned to a six month

supervised or home exercise program. They found that the

supervised exercise subjects were not only healthier, but

they had decreased their pain reports, had decreased their










medical visits, and had fewer relapses. Additionally, the

significant factors found to relate to decreased pain were

the number of exercise sessions completed, decreased body

fat, and increased aerobic fitness.

In summary, the studies reviewed on the relationship

between exercise and psychological functioning are

inconclusive. Despite these discrepant findings, there does

appear to be some psychological benefits associated with

exercise. The role of exercise in treating chronic low back

pain also appears to be a beneficial treatment modality, but

the role of exercise in the chronic pain syndrome needs

further investigation. Given the suggestion that trunk

extension strength is the most severely affected area in low

back pain patients, exercise and rehabilitation of this area

is a viable treatment modality open for investigation

(Smidt, Herring, Amundsen, Rogers, Russell, & Lehmann,

1983).

Exercise of the Low Back

Recent investigators who have suggested that physical

reconditioning can be beneficial for the low back pain

patient emphasize that exercise regimens should recondition

the specific atrophied muscles (Feuerstein et al., 1987;

Mayer et al., 1985). Chronic disuse of specific spinal

muscles can exacerbate existing low back pain (Rosomoff,

1985). In addition to preventing exacerbation of the pain

experience, strengthening the muscles of the low back and










lower extremities may also lead to improvement in other

areas of functioning. For example, Fredrickson, Trief,

VanBeveren, Yuan and Baum (1987) followed 80 chronic pain

patients referred to a multimodal six week outpatient

treatment program. They found that increased functional

strength after treatment was the best predictor of

successful outcome which was defined as decreased pain

experienced, increased activity levels, and/or return to

work.

Increasing the strength and elasticity of the lumbar

extension muscles should decrease chronic low back pain.

This is consistent with Keefe and Gil's (1986) pain-spasm-

pain model of the chronic pain patient. These authors state

that an initial painful event leads to a reflexive muscle

spasm, vasoconstriction, and the release of pain producing

substances. With time, this minimizes the pain and

additional spasm through reduced movement. This limited

movement, in turn, leads to muscle shortening and the

inactive muscles atrophy. The shortened, atrophied muscles

then predisposes the patient to more spasm and increased

pain. Therefore, increasing the physical fitness of the

lumbar muscles should decrease pain in patients with chronic

low back pain.

Jones, Pollock, Graves et al. (1988) propose three

primary reasons for myofacial low back pain: specific

muscular responses, type of muscle fiber, and chronic disuse










atrophy. They describe two muscle fiber types in the low

back--fast and slow twitch fibers. The fiber types

determine not only the patient's strength, but their ability

to endure work-loads for varying lengths of time. Fast

twitch muscle fibers are suggested to fatigue much more

readily than slow twitch fibers which may predispose the

individual to reduced muscular strength and subsequently

lead to injury and pain. These investigators report that

based on endurance measures taken across a large healthy

sample, 30% of the general population has predominantly fast

twitch lower back muscles, 10% has predominantly slow

twitch, and 60% has a fairly even mixture of the two types

of fibers. Since a majority of the population has a

combination of fiber types, these authors suggest that

understanding of an individual's predominant fiber type

should be determined by computing a ratio of their lower

back muscles' strength to their endurance under a work load.

In summary, results of unpublished studies testing a

diverse population of subjects on the MedXTM lumbar

extension machine suggest that 30% of the general population

has a high percentage of fast twitch fibers and 60% has a

mixture of fast and slow twitch fibers. Based on these

studies, it is proposed that the lumbar extensor muscles are

proportionately weaker in the extended position and stronger

in the flexed. These authors further conclude that

individuals with predominantly high twitch muscle fibers









38

will have a low work endurance ability and are therefore at

high risk for injury to the low back (Jones et al., 1988).

Additionally, these investigators suggest that current

modes of exercising these muscle groups are ineffective in

that the hip extensors (legs and buttocks muscles)

predominate and interfere with the strengthening of the

lumbar extensor muscles. Exercise on the MedXT lumbar

extension machine is proposed to be a superior exercise

modality in that the pelvis and large thigh and gluteal

muscles are restrained and stabilized which isolates the

lumbar extensors for maximum exercise benefits. Studies

utilizing the MedXT lumbar extension machine have found

that normal subjects trained on the MedXTM lumbar extension

machine have significant increases in low back strength,

despite their previous exercise experience (Pollock,

Leggett, Graves et al., 1989). Hence, Jones et al. (1988)

propose that these muscle groups must be isolated and

exercised in order to increase their strength and thereby

reduce the risk of low back injuries. They conclude further

that routine exercise on the MedXT lumbar extension machine

is the only available method which isolates and strengthens

the lumbar extensor muscles.

There is currently only one study addressing the

benefits of MedXT training for individuals with low back

pain. This study examined a population of 12 mild low back

pain subjects who exercised on the MedXT lumbar extension











machine for 10 weeks. Training produced significant

increases in lumbar extension strength, as well as decreases

in self-reported pain, and increases in functional status as

measured by the Oswestry Low Back Pain Disability

Questionnaire (MacMillan et al., 1988, unpublished data).

While this study suggests that lumbar extensor

strengthening may be beneficial in treating patient's with

chronic, mild, low back pain, there are several

methodological weaknesses. It is unclear how the term

"mild" low back pain was operationalized. It is also

unclear if mild represents limited pathophysiological

findings, limited psychological distress, or both. In

addition, a low back pain control group was not included.

Previous research suggests that the MedXT lumbar

extension machine effectively strengthens lumbar extensor

muscles and that this strengthening is superior to other

methods of lumbar exercise for healthy individuals (Graves

et al., 1990; Pollock et al., 1989). In addition, pilot

data (MacMillan et al., 1988) suggests that exercise on the

MedXT lumbar extension machine may be a beneficial

treatment modality for patients with mild, low back pain.

Since low back pain patients are a heterogeneous population

comprised of differing levels of physical, psychological and

social involvement with their pain, more research is needed

to investigate the benefits of the MedXT lumbar extension

machine for these patients.











Hypotheses

The literature reviewed suggests that physical

reconditioning is important in treating patients with

chronic low back pain, particularly in order to recondition

specific atrophied muscles. The chronic back pain patient

avoids activity in an attempt to decrease pain which in

turn, may result in increased pain and psychological

distress. Feuerstein et al. (1987) suggested that

strengthening the muscles of the low back and lower

extremities is an important correlate of improvement after

treatment in the chronic low back pain patient, but this

area of investigation has been neglected. While many

treatment programs for the chronic pain patient include

physical and psychological components, the specific effects

of physical reconditioning on functional and psychological

outcomes are poorly understood.

Jones et al. (1988) propose that the MedXT lumbar

extension machine has the ability to isolate and strengthen

the weaker extensor muscles of the low back in healthy

subjects and subjects with mild low back pain. The meaning

of the previous research with mild low back pain patients is

unclear in that there is no differentiation of mild with

respect to mild physical or mild psychological involvement.

In summary, there has been no research to date investigating

this machine as a treatment modality for a diverse chronic

low back pain population.











The current study examined the specific benefits of

exercise performed on the MedXTM lumbar extension machine

with a diverse chronic low back pain population. It was

hypothesized that subjects completing MedXM training would

show significant improvement in low back muscle strength as

compared to the control group. It was further hypothesized

that this strengthening program would lead to significant

improvement in post-treatment physical and psychosocial

dysfunction as assessed by subscales of the Sickness Impact

Profile. Physical reconditioning on the MedXT lumbar

extension machine was also hypothesized to result in

decreased pain reports and psychological distress

(specifically anxiety and depression). These hypotheses

were based on previous research which suggested that

exercise can decrease anxiety and depression. Reductions in

self-reported pain were believed to be important given that

it is verbal complaints that result in patient referrals for

continued treatment (Kleinke & Spangler, 1988). Finally, it

was hypothesized that adherence to the training program on

the MedXT lumbar extension machine and maintenance of

therapeutic gains would be predicted by the subject's self-

efficacy expectations, and social support (measured by the

Exercise Locus of Control Scale and the Social Support

subscale of the West Haven-Yale Multidimensional Pain

Inventory, respectively). This hypothesis is consistent

with the finding that self-efficacy expectations influence









42

an individual's performance in a given activity, and with

the finding that social reinforcement effects an

individual's pain coping abilities and adherence to exercise

programs. Given the hypothesis that patients avoid exercise

based on their negative past experiences, self-efficacy

beliefs were believed to contribute to the individual's

motivation to continue in a rigorous exercise program and

hence predict attrition (or treatment drop-outs).















CHAPTER 2
METHOD


Subjects

Fifty-five subjects (34 males and 21 females) were

referred for rehabilitation on the MedXTM lumbar extension

machine by an orthopaedic surgeon specializing in disorders

of the spine. The average age of the subjects was 45 years

(ranging from 22 to 70 years). The sample was predominantly

caucasian (91%) and married (76%). Subjects experienced low

back pain for an average of eight years (ranging from 1 to

26 years), had two surgeries or less, were ambulatory, and

were not dependent (daily use) on narcotic analgesics.

Fifty-four percent of the subjects were receiving workmen's

compensation or disability payments as their primary source

of income and the average time out of work due to pain was

37 months (ranging from 0 to 168 months). Thirty-five

percent of the subjects were employed full-time and 46% were

unemployed due to back pain. The onset of pain was

described as sudden and was related to an automobile or work

accident for 83% of the sample.











Equipment and Measures

MedXT Assessment and Training

MedXT testing consisted of an isometric test of lumbar

extension strength at seven different testing points within

each subjects range of motion up to a maximum arch of 72

degrees. Subjects were seated in the MedXTM lumbar

extension machine and their knees were positioned so that

their femurs were parallel to the seat. Subjects were

secured in place by specially designed femur and thigh

restraints used to stabilize the pelvis. To begin the test,

subjects were locked into between 48 and 72 degrees of

flexion and instructed to extend their back against the

upper back pad. Once maximal tension had been achieved, the

subjects were instructed to maintain a maximal contraction

for one to two seconds before relaxing. A 10 second rest

interval was provided between each isometric contraction

while the next angle of measurement was set. During the

contractions, the subjects were provided visual feedback of

their generated force and were verbally encouraged to give a

maximum effort. A maximum isometric contraction was

measured at each of the seven angles and a computerized

force curve was obtained. The subject then exercised

through flexion and extension with a work load of 1/2 their

peak isometric strength until fatigued. At this point, a

second force curve was generated. The shape of the two

force curves were noted for similarity and the difference











between them was a measure of fatigue. Hence, the first

MedXT assessment provided a baseline isometric strength

curve.

For the next two consecutive clinic visits, subjects

were instructed in the proper use of the MedXTM lumbar

extension machine under the supervision of one of three

registered physical therapists. MedXTM instruction and

training consisted of isotonic exercise at a work load of

1/2 the subject's peak isometric strength (torque in N.m).

When the subject exceeded 12 repetitions, the resistance was

increased 5 foot pounds. When subjects returned for their

fourth clinic visit, they were again administered the

isometric strength test which generated a second force

curve. In order to control for familiarity and variable

learning effects, this testing session was used as the pre-

treatment strength measure. Subsequent training sessions

were performed twice per week for four weeks followed by

once per week for an additional six weeks. Strength curves

were then re-generated for assessment of changes in muscle

strength post-exercise.

Self-Report Questionnaires

All subjects completed a demographic questionnaire

which consisted of questions to assess race, sex, age,

marital status, occupation, work status, and litigation

status. Questions pertaining to the subject's pain history

included whether there was a precipitating event to their











pain problem, the duration of their pain problem, previous

treatment interventions (i.e., prior hospitalizations,

surgeries, physical therapy modalities, and other

medical/psychological interventions), and current

medications. At the end of the study, subjects were

administered a second questionnaire to assess their

utilization of medical interventions during the study (See

Appendix A and B.).

Measures of self-efficacy

Exercise Objectives Locus of Control Scale. This

measure is a standardized instrument which was used to

assess the subject's perception of control over and ability

to master the MedXT exercise regimen. The Exercise

Objectives Locus of Control Scale (EOLCS) was developed by

McCready and Long in 1985. The test has 18-items (e.g., My

own actions will determine whether or not I achieve my

exercise objectives) which are responded to on a scale of 1

to 5 (l=strongly agree, and 5=strongly disagree). Three

scores are obtained: an internal control factor, a powerful

other factor, and a chance control factor. These three

factors reflect the individual's perceived ability to master

an exercise objective and provided information as to their

perceived competence in completing the task. This test has

good psychometric properties and was normed on males and

females ranging from 17 to 55 years in age. Cronbach's

alphas were 0.86 for internal control, 0.79 powerful other,










and 0.57 for chance. Test-retest (three to four months)

were high for the powerful other and chance subscales (0.72

and 0.60, respectively), but were somewhat lower for the

internal scale (0.32). This test was originally developed

as a measure of predicting attrition, but it subsequently

was not fund to be solely predictive of attrition. It was

found to be predictive of adherence to an exercise program

based on the individual's self-efficacy expectations and if

the individual's participation was perceived as a stress and

tension reducing mechanisms, in contrast to a perceived

social event.

Activity Recall Questionnaire

This measure was originally developed by Blair,

Haskell, Ping Ho et al. in 1985 to assess changes in an

individual's habitual exercise patterns. It provides a

general measure of the subjects' routine activities (e.g.,

climbing stairs, walking, and household chores) in addition

to their participation over a one week period in

recreational activities. It has been used in a large

epidemiology study which examined exercise habits in over

2,000 subjects (Blair, Haskell, Ping Ho et al., 1985). This

activity measure was found to significantly correlate with

dietary energy intake in a study of 495 males and 545

females. It has also been shown to be positively and

significantly correlated with physiological changes in

maximum oxygen uptake and body fat after exercise (Sallis,











Haskell, Wood et al., 1985). Since it was suggested that

past exercise experience may predict outcome, this measure

was used to predict compliance and completion of the

treatment program.

West Haven-Yale Multidimensional Pain Inventory

Subjects completed the West Haven-Yale Multidimensional

Pain Inventory (WHYMPI; Kerns, Turk, & Rudy, 1985). This is

a 52-item self-report questionnaire that is consistent with

a cognitive-behavioral conceptualization of the chronic pain

syndrome. Studies using this brief measure report that it

is psychometrically sound and when used in treatment outcome

studies it has been found to be a reliable and valid

assessment instrument for chronic pain patients (internal

consistency ranging from 0.70 to 0.90, and stability

coefficients ranging from 0.62 to 0.91).

There are three parts of this inventory that examine the

impact of pain on the subject's lives by addressing their

perception of positive and negative social support, their

activity levels, and their current levels of experienced

pain and depression. The positive/negative social support

subscales were used to predict attrition and therapeutic

gains. A subject's perception of their pain intensity was

also measured with this questionnaire by having them rate

their current pain and their pain for the last week.











Mental Health Inventory

This measure was included to assess changes in overall

psychological well-being, and changes in anxiety and

depression. Factor analysis of the Mental Health

Inventory's (MHI) 38 questions indicates that there are two

higher order factors and five lower order factors (Veit &

Ware, 1983). The factor of psychological well-being is

defined by two lower order factors of General Positive

Affect and Emotional Ties. A second factor of psychological

distress is defined by three lower order factors of Anxiety,

Depression, and Loss of Behavioral/Emotional Control.

Additionally, a Life Satisfaction score is obtained. The

MHI is a good psychometric instrument with an internal

consistency reliability coefficient of 0.94 and a one week

test-retest reliability of 0.80 (Veit & Ware, 1983). The

two higher order factors were used in this study to assess

psychological well-being, and depression and anxiety.

Perceived Stress Scale

The Perceived Stress Scale (PSS, Cohen, Kamarck, &

Mermelstein, 1983) is a 14-item questionnaire used to

measure a general area of perceived stress. There are three

general subscales generated with this measure; physical

disability, psychosocial distress, and work/recreation

dysfunction. This measure was incorporated due to the

findings that chronic pain patients experience psychological

distress and to the belief that a particular event is not











stressful in itself, but it is the perception of the

individual that an event is stressful that results in a

concomitant stress response. This measure has moderate

test-retest reliability (0.85 after two days, and 0.55 after

six weeks) and validity coefficients are reported from 0.52

to 0.76. In addition, this measure is reported to be a good

predictor of health related outcomes as assessed with PSS

scores and subsequent seeking of medical services (Cohen,

Kamarck, & Mermelstein, 1983).

Sickness Impact Profile

The Sickness Impact Profile (SIP, Bergner, Bobbitt,

Pollard, Martin & Gilson, 1976) is a 136-item test which was

selected to assess changes in functional abilities. The

measure provides scores for the impact of an illness in

three general dimensions; physical disability, psychosocial

dysfunction, and other dysfunction (work and recreation).

For purposes of this study, the physical and psychosocial

dysfunction dimensions were utilized. Original validation

was performed on a diverse medical population and it was

found to be significantly correlated with the patient's

self-report of physical disability, physician ratings of

their disability, and with daily activity diaries (0.29 to

0.52, Pearson correlation coefficients).

More recently, this measure was used to assess

functional status changes in chronic low back pain patients

following treatment interventions (Follick, Smith, & Ahern,











1985). For this population, validity of this measure was

found in significant correlations between up/down time, and

emotional distress as measured by the MMPI (0.29, Pearson

correlation coefficient, and 0.52-0.64 canonical variate

coefficients).

Procedures

Subjects were consecutively referred by an orthopaedic

surgeon for rehabilitation on the MedXTM lumbar extension

machine. All subjects received a complete medical

evaluation by the orthopaedic spinal specialist in order to

rule out the presence of organic pathology which would

require surgical intervention. Patient referrals were

informed that the exercise machine was involved in a

research protocol and were requested to participate. After

completing an informed consent, subjects completed the

demographic and self-report questionnaires. The

experimental protocol was approved by the institutional

review board of the University of Florida.

Subjects then returned for a baseline test followed by

two orientation and practice exercise sessions on the MedXTM

lumbar extension machine. These orientations provided the

subjects information on proper use of the equipment and

enabled the investigators to obtain reliable lumbar

extension force curves. Subjects then returned for a fourth

session and were tested for lumbar extension strength as was

previously described.











After the fourth session, subjects were randomly

assigned to a treatment condition which consisted of 14

exercise sessions or to a ten week wait-list control group.

Random assignment of the first 55 eligible patients resulted

in 32 subjects being assigned to the treatment group and 23

to a wait-list control group.

Before the fourth MedxTM session, subjects were re-

administered the EOLCS and the pain rating scale. This

enabled the investigators to evaluate the effects of

exposure to the training machine.

Experimental Group

Subjects began exercising on the MedXTM lumbar

extension machine twice per week for six weeks followed by

one day per week for an additional six weeks. MedXT

training consisted of variable resistant isotonic exercises

at a work load of 1/2 the subject's peak isometric strength.

At the end of 12 weeks, subjects were re-tested for lumbar

extension strength and the self-report questionnaires were

completed (treatment history, EOLCS, WHYMPI, MHI, PSS, SIP,

and activity questionnaire).

Wait-List Control Group

This group of subjects received the same complete

medical evaluation, MedXT orientation, and MedXT lumbar

strength testing as the experimental group. They also

completed all questionnaires prior to exposure to the MedXT

lumbar extension machine. They then repeated the EOLCS and











pain rating prior to their second lumbar strength test.

After lumbar strength testing, this group was asked to wait

10 weeks before beginning treatment. They were requested

not to change their current exercise and activities or their

methods of treating their pain. At the end of 10 weeks,

these subjects again completed all self-report

questionnaires and were retested on the MedXT lumbar

extension machine. They then followed the same treatment

protocol as the experimental group.

Statistical Analysis

The design of this study enabled the investigator to

measure changes on measures of psychological status,

functional abilities, and physical strength as a function of

treatment. Subjects were randomly assigned to a wait-list

control or treatment group. Pre- and post-treatment

differences on demographic variables and medical treatment

histories were addressed with multivariate analysis of

variance and Chi-square statistics.

Analysis of physical strength

Due to the chronicity and physical limitations of this

population, most subjects were unable to complete a full

range of motion within a standard arch of 72 degrees. In

order to standardize the data for group comparisons,

regression equations (Torque=angle(x) + intercept) for pre-

and post-treatment MedXT testing sessions were computed for

each subject based on their actual performance within their









54

varying range of motions. This enabled the investigator to

obtain the slope and intercept of the regression line

resulting from the generated force curve for each subject.

The pre-treatment slopes and intercepts were used as a

covariate in an analysis of variance for between group

differences post-treatment. Change scores between pre- and

post-treatment were used as the dependent variable.

Additionally, the estimated torque values based on the

regression analysis at standardized angles (angles of 0, 12,

24, 36, 48, 60, and 72 degrees) within the subject's range

of motion were compared post-treatment utilizing the pre-

treatment standard values as the covariate in an analysis of

covariance.

Analysis of psychological measures

Psychological measures for between group comparisons

were analyzed using pre-treatment scores as the covariate in

a multivariate analysis of covariance for between group

differences. Change scores were used as the dependent

variable. Secondly, locus of control (internal and

external), activities, positive social support, and the pain

rating scale were entered into a step-wise multiple

regression analysis for prediction of outcome as assessed by

their relationship with the post-treatment intercept.

Finally, Pearson Correlation Coefficients were computed

between the variables of post-treatment strength (as

measured by the changes in intercept scores post-treatment),









55

self-reported pain, and psychological variables of distress,

dysfunction, and social support to address the magnitude of

the relationship between psychological measures and changes

in strength.














CHAPTER 3
RESULTS

There were no significant differences between groups on

demographic variables or pain histories pre-treatment.

There were also no differences between groups in their

medical examination (i.e., grimacing, ambulation, or

cooperativeness). Subjects were most frequently diagnosed

with combinations of low back pain with sciatica (56%), low

back pain without sciatica (43%) myofacial syndrome (50%),

spinal stenosis (28%), lumbar spondylosis (46%) and lumbar

instability (43%).

There were no significant differences between groups in

age, duration of their pain problem, medication usage, or

previous treatment histories. There was a significant

difference found between groups in the time since last

worked with the control group reporting more time since they

last worked compared to the treatment group (F(1,42)=4.10, R

< 0.05). When addressing medical treatments and activities

during the study, there were no differences found at the end

of the protocol between the control and treatment groups.

(See Table I.)











TABLE I
SUBJECT CHARACTERISTICS OF THE WAIT-LIST CONTROL
AND TREATMENT GROUPS STUDIED FOR EFFECTS OF
EXERCISE OF THE LOW BACK MUSCLES



Treatment Control
Group Group

N=31 N=23


Sex
Male
Female


Unemployed due to
Back Pain

Diagnosis

Low back pain with
sciatica
Low back pain
without sciatica
Myofacial Syndrome
Spinal Stenosis
Lumbar Spondylosis
Lumbar Instability

Average age

Average duration
of Pain in months

Time since
last worked
in months

Daily Hours in
Pain
Pre-treatment


42%


44 (22-70 yrs.)


84 (12-312 mos.)



22 (0-132 mos.)



13 (2-24 hrs.)


52%


47 (25-70 yrs.)


89 (12-288 mos.)



56 (1-168 mos.)*



15 (2-24 hrs.)


* E < 0.05











Physiological Results

It was hypothesized that exercise on the MedXTM lumbar

extension machine would strengthen the low back extensor

muscles. T-Test results indicated that there were no pre-

treatment differences between groups in measures of

isometric strength as defined by the pre-treatment intercept

scores and slopes of the regression line. At post-treatment

utilizing an analysis of covariance with pre-treatment

scores as a covariate and the change scores as the dependent

variable, there were no differences between groups in the

slope of the isometric strength curve, but there were

significant differences between the intercepts,

(F(2,52)=6.50, R < 0.01). Results indicated that the mean

intercept significantly increased in the treatment group

while it remained the same for the control group. Given the

drastic decline in the number of subjects at the 72 degree

angle, the slope of the regression line has been graphically

portrayed twice. Figure I represents the regression line

with a full range of motion with only 24% of the subjects

completing the 72 degree angle, and Figure II represents the

regression line up to 60 degrees which encompasses 65% of

the sample. (See Figures I and II.). These findings

suggest that while the linear increase in strength was

consistent across the subject's range of motion between the

two groups, the treatment group generated consistently more

force post-treatment. When addressing each standard angle










utilizing the pre-treatment torque as a covariate, the

results were consistent with the increases in intercept and

indicated that the treatment group significantly increased

their strength at all angles within the subject's range of

motion. (See Table II.)

Psychological Results

The second hypothesis suggested that increased strength

in the low back muscles would be associated with increased

functional abilities. The physical and psychosocial

subscales of the Sickness Impact Profile were utilized to

address this hypothesis. Results of the pre-treatment

analysis indicated that the control group reported

significantly more physical and psychosocial dysfunction

when compared to the treatment group. Controlling for pre-

treatment differences by utilizing the pre-treatment scores

as a covariate in an analysis of covariance, there were

significant differences between the groups in pre/post-

treatment change scores on the physical dysfunction scale.

The treatment group reduced their scores in reported

physical dysfunction after exercise and the control group

increased in their reported physical limitations

(F(2,52)=4.77, R < 0.03). A similar trend was found on the

psychosocial subscale. Controlling for pre-treatment

differences by utilizing the pre-treatment scores as a

covariate in an analysis of covariance, there were

significant differences between the groups in pre/post-


























12 24 36 48 60 72

ANGLE


PRE-TREAT
+ PRE-CONTROL


-- POST-TREAT
-- POST-CONTROL


FIGURE I
PRE-POST TREATMENT TORQUE
(REGRESSED MEANS RANGING FROM 0 TO 72 DEGREES)


TORQUE


250


200



150


100o









TORQUE
250


200


150


100


50
0 12 24 36 48 60 72

ANGLE


PRE-TREAT
-- PRE-CONTROL


-+- POST-TREAT
-- POST-CONTROL


FIGURE II
PRE-POST TREATMENT TORQUE
(REGRESSED MEANS RANGING FROM 0 TO 60 DEGREES)












TABLE II
PHYSIOLOGICAL MEASURES


TREATMENT GROUP CONTROL GROUP
PRE/POST TREATMENT PRE/POST TREATMENT STATISTIC
(STANDARD DEVIATION) (STANDARD DEVIATION) p VALUE


MEAN INTERCEPT


MEAN SLOPE


73.2 104.1
(45.1) (63.5)

1.4 1.4
(0.8) (0.7)


73.4 73.6 F(2,52)=6.50
(54.6) (58.8) R<0.01

1.9 1.7 ns
(1.1) (0.9)


MEAN TORQUE AT SEVEN STANDARD


ANGLES IN DEGREES:

ANGLE 0



ANGLE 12


ANGLE 24



ANGLE 36



ANGLE 48



ANGLE 60



ANGLE 72


70.9
(43.9)
(N=31)

91.2
(47.3)
(N=31)

108.9
(51.4)
(N=31)

129.1
(55.0)
(N=30)

143.2
(63.1)
(N=28)

157.9
(73.9)
(N=23)

170.3
(67.8)
(N=9)


100.7
(63.4)
(N=31)

123.5
(64.5)
(N=31)

140.9
(67.2)
(N_=31)

158.4
(69.9)
(N=31)

177.0
(74.6)
(N=29)

193.3
(82.5)
(N=27)

211.5
(68.6)
(N=12)


74.0
(54.5)
(N=23)

96.5
(60.6)
(N=23)

121.7
(68.8)
(N=23)

149.1
(77.2)
(N=22)

160.2
(86.1)
(N=17)

195.5
(100.3)
(N=12)

148.5
(59.4)
(N=4)


72.2
(58.7)
(N=23)

94.1
(56.5)
(N=23)

116.6
(57.9)
(N=23)

139.6
(61.5)
(N=22)

162.3
(66.7)
(N=19)

173.6
(67.0)
(N=12)

156.4
(62.2)
(N=5)


F(2,51)=6.89

E<0.01

F(2,51)=9.46

E<0.003

F(2,51)=10.93

p<0.002

F(2,48)=10.17

E<0.002

F(2,41)=5.38

E<0.02

F(2,31)=13.77

R<0.0008

F(2,10)=7.53

E<0.02











treatment change scores on the psychosocial dysfunction

scale. The treatment group decreased their scores and the

control group increased in their reported psychosocial

dysfunction (F(2,52)=5.05, E < 0.03). There were no

pre/post-treatment differences in recreational activities or

routine exercise regimens on the activities questionnaire.

(See Table III.)

The third hypothesis proposed that exercise and

increased low back strength would result in beneficial

reductions in psychological distress and pain. Analysis of

pre-treatment scores on perceived stress and measures of

anxiety and depression (defined as psychological distress on

the Mental Health Inventory) indicated that both groups

experienced severely high levels of perceived stress and

psychological distress pre-treatment and the control group

expressed significantly higher levels than the treatment

group. Analysis of covariance which used pre-treatment

scores as the covariate and change scores as the dependent

measure revealed no treatment differences between groups for

stress, anxiety and depression, or psychological well-being.

Although all subjects reported high levels of stress and

distress over the course of the study, there were no pre-

treatment difference between groups on the level of self-

reported pain as measured by the pain subscale of the

WHYMPI. In contrast, utilizing pre-treatment pain scores as

the covariate in an analysis of covariance for changes in











TABLE III
PSYCHOLOGICAL DYSFUNCTION AND PAIN
PRE/POST-TREATMENT MEANS AND STANDARD DEVIATIONS


Treatment Group Control Group
Pre/posttreatment Pre/posttreatment
(SD) (SD) p Value


Sickness Impact
Profile:

Physical
Dysfunction

Psychosocial
Dysfunction

Mental Health
Inventory:

Psychological
Distress

Psychological
Well-Being

West Haven-Yale
Multidimensional
Pain Inventory:

Pain Subscale


Positive Support
Subscale

Negative Support
Subscale


9.1 7.7 15.2 19.3
(9.3) (9.4) (10.4) (15.6)

12.5 10.3 20.8 24.8
(14.3) (12.8) (18.0) (23.7)


E<0.03


R<0.03


58.8 59.0 71.7 70.3
(18.8) (20.9) (28.9) (32.5)

51.3 52.2 45.1 46.8
(13.9) (14.5) (18.1) (19.0)


3.4 2.9
(1.6) (1.7)

3.6 3.4
(1.3) (1.5)

1.2 1.2
(1.0) (1.1)


3.7 4.1
(1.6) (1.5)

2.6 3.0
(1.7) (1.5)

2.1 1.7
(1.5) (1.4)


E<0.002


ns


ns


Exercise Locus
of Control:


23.3 23.9
(5.2) (4.4)

12.0 11.7
(3.7) (3.7)


21.8 19.9
(5.2) (6.7)

11.6 13.1
(3.8) (3.8)


Internal
Control

Other
Control


R<0.02


p<0.04











reported pain, there was a significant difference found

between groups with the treatment group reporting a

significant reduction in pain and the control group

reporting an increase in pain (F(2,51)=6.83, R < 0.002).

It was originally hypothesized that social support,

self-efficacy, and pain reports would predict attrition or

adherence to the exercise program, and therapeutic gains.

Since attrition was limited (i.e., one drop-out), factors

associated with attrition could not be ascertained.

Analysis of the Social Support subscales of the WHYMPI

indicated pre-treatment differences in perceived support

with the treatment group reporting higher levels of positive

support and the control group higher levels of negative

support. In contrast, there were no post-treatment

differences in perceived negative or positive support which

may be reflective of a simple regression towards the mean.

In assessing the individual's perceived ability to master

the exercise program, there were no pre-treatment

differences between groups on internal or external locus of

control, but there were significant post-treatment

differences found. An analysis of covariance with pre/post-

treatment change scores indicated that the treatment group

maintained a high internal locus of control whereas the

control group decreased on internal locus of control

(F(2,50)=6.07, R < 0.02) and changed to a perceived external

locus of control (E(2,50)=4.59, R < 0.04). (See Table III.)










In order to assess pre-treatment predictors of

therapeutic gain, the five variables measuring positive

support, pain, past week activity levels, and internal or

external locus of control were entered into a stepwise

regression model with post-treatment intercepts as the

dependent variable. The regression analysis indicated that

28% of the variance was attributable to pre-treatment

measures of the past weeks activity level, pain, and

external locus of control (F(3,52)=6.22, R < 0.001). The

relationship between pre-treatment pain and post-treatment

intercepts accounted for 19% of the total variance in the

model and was the only significant variable influencing

strength outcome [F(4,48)=4.81, p < 0.002). (See Table IV.)

In order to assess the relationship between physical

strength changes, self-reported pain, and psychological

distress, a Pearson's correlational analysis was performed

looking at pre/post-treatment intercept change scores and

post-treatment psychological measures. Results indicated

that increased strength was positively correlated with an

internal locus of control (r=0.34, R<0.01), and negatively

correlated with higher levels of dysfunction on the physical

and psychosocial impact scales of SIP (r=-0.56, R<0.0001 and

[=-0.45, E<0.0006, respectively), with higher pain reports

(r=-0.39, E<0.004), and with increased psychological

distress on the MHI (r=-0.30, R<0.03). On the other hand,

high reports of pain post-treatment were not only negatively











related to increased strength, but with higher levels of

internal locus of control (r=-0.53, E<0.0001) and with

increased psychological well-being as measured by the MHI

(r=-0.56, R<0.0001). Pre/post-treatment changes in self-

reported pain were not significantly correlated with any of

the above variables. (See Table V.)








68





TABLE IV
MULTIPLE REGRESSION OF THE RELATIONSHIP OF PRE-TREATMENT
PSYCHOLOGICAL VARIABLES TO POST-TREATMENT INTERCEPT VALUES


Step Variable Model Partial F p Beta
R2 R2 Statistic Value Weight

1 Pain 0.19 0.19 12.12 0.001 -12.3

2 Activity 0.24 0.05 3.05 0.08 12.7

3 External LOC 0.28 0.04 2.52 0.12 3.5

4 Internal LOC 0.28 0.01 0.69 0.41 1.3








TABLE V
CORRELATION ANALYSIS OF STRENGTH CHANGES
(CHANGES IN INTERCEPT SCORES PRE/POST-TREATMENT)
AND POST-TREATMENT PSYCHOLOGICAL MEASURES

VARIABLE 1 2 3 4 5 6 7 8 9 10 11 12
1. INTERCEPT
CHANGE SCORES --


2. PHYSICAL
DYSFUNCTION -.56
3. PSYCHOSOCIAL
DYSFUNCTION -.46
4. PAIN
POST
TREATMENT -.39
5. HOURS IN
PAIN -.34
6. PAIN
CHANGE SCORE .04
7. DISTRESS -.30
8. WELL-
BEING .13
9. STRESS -.25
10.INTERNAL
LOC .34
11.EXTERNAL
LOC .04
12.NEGATIVE
SUPPORT .02
13.POSITIVE
SUPPORT .03


.84


.68 .67

.65 .64 .72


.21 .20
.65 .84


.42
.63


.28
.48


.12


-.40**-.64** -.56** -.40** -.10
.54 .68 .67 .44 .18

-.63 -.67 -.53 -.41 -.26


.18 .23

.14 .38

.13 .01


-.83
.88 -.78

-.57 .39 -.54


.10 .02 .21 .21 -.09

.23 .26 -.02 .40 -.40


.19 -.38

.24 -.13 -.03


.13 .06 .07 -.02 .09 .05 -.27 .19 -.40


* p < 0.05
** E < 0.01














CHAPTER 4
DISCUSSION

This study examined the effects of exercise on the

MedXT lumbar extension machine in a chronic low back pain

syndrome population. It was hypothesized that after a 12

week exercise program subjects would improve in lumbar

extensor strength and that improvements in strength would be

associated with decreased physical and psychological

dysfunction.

The findings of this study confirmed that exercise on

the MedxTM lumbar extension machine substantially increased

low back strength in a sample of chronic low back pain

patients. These findings are of particular importance given

the chronicity and disability reported by this sample.

Additionally, increased strength was related to improved

physical and psychosocial functioning as measured by the

Sickness Impact Profile. On this measure, the treatment

group decreased in their report of dysfunction while the

control group increased on measures of physical and

psychosocial impairment. Interestingly, despite reporting

improved physical and psychosocial functioning, there were

no differences or changes in daily activity levels.

Exercise on the MedXTM lumbar extension machine was also

related to significant changes in self-reported pain.

70











Again, the treatment group decreased their pain reports

while the control group reported even higher levels of pain

at the end of the study. Changes in pain and physical

dysfunction were hypothesized to result in decreases in

psychological distress (depression, anxiety, and stress),

but the findings of this study did not support this

hypothesis. Subjects in this study reported significantly

high levels of depression, anxiety, and stress prior to

entering the protocol and at the end of treatment, both

groups continued to report significantly high levels of

psychological distress.

It was hypothesized that pre-treatment measures of

self-efficacy, pain, and perceived social support would be

related to adherence to the treatment program and to

therapeutic gains. All but one subject completed the

treatment program; therefore, attrition could not be

investigated. With respect to predicting treatment outcome

from pre-treatment measures of pain, activity levels, self-

efficacy, and social support; pre-treatment pain was most

predictive of post-treatment strength changes.

Additionally, there was a strong relationship between

changes in strength and perceived self-efficacy (as measured

by the Internal Locus of Control subscale of the Exercise

Objectives Locus of Control Scale). Contrary to the

original hypotheses, social support was not related to

treatment outcome measures.











Physiological Findings

Subjects were tested for isometric strength of the

lumbar extensor muscles on the MedXTM lumbar extension

machine at the beginning and end of this 12 week treatment

protocol. Due to the chronicity and physical limitations of

this sample, many of the subjects were unable to complete a

full 72 degrees range of motion. In fact, 75% of the

population could not flex at the 72 degree angle and 35%

could not flex at 60 degrees. Despite these limitations in

range of motion, statistical analysis resulted in finding

that the treatment group as compared to the control group

significantly increased in their generated torque values

following only 14 exercise sessions over a 10 week period.

The statistics used to assess strength changes pre- and

post-treatment standardized the data for group comparisons.

Given that subjects could not complete a full range of

motion, isometric testing points varied a few degrees across

subjects within their differing abilities. Hence,

regression equations were computed for each subject pre- and

post-treatment and the resultant slopes and intercepts of

the regression lines were utilized for measuring change.

Results of the statistical analysis indicated that there

were no differences between groups in the slopes of the

regression line pre- or post-treatment. However, the

control group failed to generate a straight line and

exhibited a marked deviation at the 72 degree angle. Given











the small sample size at this angle (18% of the control

group) and the variability in the torque values generated,

it could be assumed that this is a measurement error and not

indicative of a non-linear relationship. Additionally, when

the slopes of the strength curve are compared ranging to

only 60 degrees of flexion (72% of the total sample), the

discrepancy in the linear relationship is no longer evident.

Based on the findings that the slopes of the isometric

strength curves were similar pre- and post-treatment,

comparisons were performed between groups on changes in the

intercept. There were no pre-treatment differences between

the intercepts of the control group and the treatment group.

Results suggest that the control group was stronger pre-

treatment at the 60 degree angle. Again, given the smaller

sample size and the increased variation in torque values at

this angle, these findings may also be an artifact of

measurement. On the other hand, given that the control

group's post-wait testing remained higher than the treatment

group's pre-treatment testing, the control group may have

been stronger at this measurement point. Nevertheless, the

decline in torque for the control group as compared to the

increase in torque for the treatment group support the

hypothesis that exercise on the MedXT lumbar extension

machine increases lumbar extension strength. Analyses of

changes in intercept indicated that the treatment group

significantly changed their intercept scores as compared to










the control group. Since an increase in intercept is

indicative of an increase in. torque generated, it was

concluded that isotonic exercise on the MedXT lumbar

extension machine resulted in increased muscle strength

post-treatment.

An additional analysis comparing change scores at each

standard angle supported the results of the changes in the

intercepts. Standard angles were calculated for each

subject based on their actual range of motion when their

testing positions were found to vary a few degrees.

Comparisons were then performed utilizing pre-treatment

standard angles as the covariate in an analysis of

covariance with changes in torque as the dependent variable.

This analysis supported the previous analysis and indicated

that training on the MedXT lumbar extension machine

increased lumbar strength by 11 to 17 percent whereas the

control group remained the same.

Psychological Findings

One of the most pronounced findings in this study was

that psychological factors found to be associated with

treatment outcome consistently improved in the treatment

group and worsened in the control group. Specifically,

treatment on the MedXT lumbar extension machine resulted in

significant improvements in reported physical and

psychosocial dysfunction as measured by the Sickness Impact

Profile. Over the course of the 12 week protocol, the










treatment group reported less physical and psychosocial

disruption while the control group reported more

impairments. This measure of impairment covers a broad

array of physical, emotional, and social situations in which

illness behaviors have a negative impact. As is evident in

the correlational analysis, the two subscales are highly

correlated and therefore, it is not surprising that finding

a change in one subscale resulted in a change in the other.

Interestingly, there were no concomitant changes found in

weekly activity levels, depression and anxiety, or stress.

These findings may be indicative of the sensitivity of the

measuring instrument, or that perceived increased physical

abilities does not readily result in increased activities.

Additionally, global measures of psychosocial functioning

may change more rapidly than more specific measures of

depression, anxiety, and stress.

The subjects participating in this study experienced

high pre-treatment levels of depression, anxiety, and stress

as measured by the Mental Health Inventory and Perceived

Stress Survey. Pre-treatment scores on the Sickness Impact

Profile were also significantly elevated. Of concern is

that the control group generally reported higher levels of

psychological distress pre-treatment as compared to the

treatment group. In addition, the control group was found

to have been unemployed due to pain for a longer duration of

time than the treatment group. It might be speculated that










the control group reported higher levels of psychological

distress in response to their less stable economic and

social situation as a result of longer durations of

unemployment. This is only speculative, but given that

physical findings, activities, pain behaviors, and pain

report were not significantly different between the groups

pre-treatment, it appears to be a reasonable hypothesis.

Analysis of differences in measures of depression,

anxiety, and stress indicated no differences between groups

at the end of the treatment study. These psychological

measures of distress were significantly elevated pre-

treatment for both groups and remained high over the 12 week

study. Studies addressing the effects of exercise on

depression and anxiety have found that mild to moderately

elevated distress appears to improve with exercise, not

severe elevations of distress (Sinyor et al., 1983). Hence,

the level of psychological distress in this study's

population was sufficiently high that more intensive

interventions may be needed to specifically address these

patients' depression, anxiety, and stress. Additionally, as

was noted in the pre-treatment analysis, the subjects

participating in this study experienced pain for extended

durations of time, were out of work for long time periods,

and half of the sample were dependent on disability or

workmen's compensation for their primary source of income.

The impact on psychological well-being of increased











chronicity of pain and the associated socio-environmental

influences was beyond the scope of this study, but these

factors surely play a significant role in the maintenance of

psychological distress. Hence, distress potentially

associated with socio-environmental factors would not be

expected to respond to an intervention of exercise, but

would require interventions aimed at ameliorating the

distressing situations. In summary, exercise on the MedXTM

lumbar extension machine improved low back strength, but did

not result in significant decreases in depression, anxiety,

and stress in this patient population.

After addressing the effects of exercise on self-

reported pain, this study found that the treatment group

decreased their pain reports while the control group

increased their report of pain. There were no pre-treatment

differences in reported pain. Hence, these findings lend

support to the hypothesis that patients with low back pain

may avoid activities that previously created pain which

results in muscular disuse and atrophy. Atrophied muscles

potentially increase pain independent of the original pain

stimuli (Feuerstein et al., 1987; Rosomoff, 1985). In

summary, exercise of the low back muscles resulted in lower

levels of reported pain in the treatment group while the

control group's report of pain continued to escalate.

An important element of this study addressed the role

of self-efficacy in treatment adherence and outcome. There









78

was only one drop out in this study; therefore adherence was

not examined. Self-efficacy was measured with the Exercise

Locus of Control Scale. This measure assessed the subjects

perceived ability to master the exercise program in terms of

internal and external locus of control. Interestingly,

there were no pre-treatment differences between groups in

locus of control with both groups reporting a higher score

on internal locus of control. At post-treatment, the

control group's mean scores changed from a higher internal

locus of control to a higher external locus of control. In

contrast, the treatment group maintained their orientation

for an internal locus of control. These findings are

consistent with self-efficacy theory and indicate that

mastery of a given behavior will influence self-efficacy

expectations which will subsequently influence behavioral

performance.

In this study, internal locus of control (increased

self-efficacy) was the only psychological measure positively

correlated with changes in strength. Pre-treatment scores

of internal locus of control (self-efficacy) were not found

to be predictive of therapeutic gain as originally

hypothesized, but increased strength (treatment success) was

highly associated with maintenance of high self-efficacy

ratings. The change of focus from an internal to an

external locus of control in the control group suggests that

as pain persists and passive treatment modalities (i.e.,








79

hot/cold packs and massage) fail to ameliorate the symptoms,

the subject's self-efficacy expectations decline and in

turn, they seek external resources for meeting their needs.

On the other hand, subjects that experienced success with

exercise and subsequent reductions in pain were more apt to

internalize their treatment goals and maintain strong self-

efficacy expectations.

It was originally hypothesized that social support

would predict attrition and therapeutic gains. Attrition

was not addressed in this study due to a high adherence

rate. Neither negative nor positive social support as

measured on the WHYMPI were predictive of changes in

strength at the end of treatment. Although the majority of

this sample were married, a supportive relationship was not

related to therapeutic changes in strength or pain. The

exercise literature suggests that social support is an

important factor in maintaining exercise objectives over

time. In contrast in the chronic pain patient, the role of

pain may be the predominant factor associated with

therapeutic endeavors which supersedes the role of social

support.

In conclusion, changes in strength were positively

associated with decreased pain reports and increased

physical and psychosocial functioning. There was no

relationship between changes in strength and psychological

distress. Additionally, the predictive ability of pre-











treatment measures of activities, locus of control, pain,

and social support was limited to 28 percent of the variance

being explained by reported pain, the previous week's

activity level, and external and internal locus of control.

Of these measures, pain was the single most influential

variable and accounted for 19 percent of the variance.

Social support did not contribute to the predictive ability

of therapeutic gain. There was only one positive

correlation with strength changes and that was with internal

locus of control (self-efficacy). Measures of psychological

distress, pain, and physical and psychosocial impairments

were significantly correlated with decreased changes in

strength.

Implications

The findings of this study support the hypothesis that

strengthening the lumbar extensor muscles in a chronic pain

population is a beneficial treatment modality. The

literature reviewed suggested that increased physical

fitness and strength was an important treatment modality,

but the specific role of exercise in a chronic low back pain

syndrome population has not been clearly documented.

Although the subjects participating in the current study

were treated in an out-patient program, they do resemble

subjects found in multidimensional pain treatment programs

in terms of their chronicity of pain problem, psychological

distress, and socio-environmental disruption. Hence, the











findings of this study have potential implications for the

severely disabled low back pain population as well as the

less disabled back pain patient as is typically found in

out-patient treatment programs. Of particular interest is

the fact that those who suffer with significantly high

levels of psychological distress and physical disabilities

exhibit beneficial changes with lumbar extension exercise.

This would suggest that a less severely disabled group might

demonstrate greater therapeutic gains with low back exercise

because of lower levels of pre-treatment pain and

psychological distress. However, the improvements found in

this chronic pain syndrome population may have been greater

given the high levels of dysfunction.

In addition to increased strength with exercise on the

MedXT lumbar extension machine, patients reported less pain

post-treatment. Decreased pain reports are important in

that it is the subjective experience of pain that results in

patients seeking health care services and it is the report

of pain that often determines treatment interventions

(Kleinke & Spangler, 1988). Hence, exercise and increased

strength of low back muscles reduces reported pain and has

the potential for a reduction in the over utilization of the

health care system associated with this population.

Although exercise on the MedXT lumbar extension machine did

not result in reported increased activity levels, there was

a decline in perceived physical and psychosocial









82

limitations. This finding suggests that life-style changes

in daily activities may not be related to perceived changes

in limitations. Hence, exercise alone does not impact on

activities of daily living and instead, socio-environmental

factors may be more determinant and should be addressed

separately.

Exercise alone did not influence measures of

psychological distress. This finding is consistent with the

literature reviewed in that these subjects reported severe

levels of psychological distress. It may be that as the

chronicity of pain and disability increase, that

psychological distress is more closely associated with

socio-environmental influences (e.g., workmen's

compensations, unemployment, availability of work, financial

stability, and adaptation to a sick role) than to physical

limitations and pain. The implications from these findings

are that patients exhibiting a chronic low back pain

syndrome improve in physical strength, and they experience a

reduction in pain following physical exercise. The

perceived or actual limitations for returning to gainful

function in society remains impaired and potentially

exacerbates psychological distress. Hence, the failure to

find improvement in psychological distress in this study

suggests that multidisciplinary treatment programs that

emphasize physical reconditioning need to address vocational










and socio-environmental factors for the successful

rehabilitation of the chronic low back pain syndrome

patient.

Treatment success was predicted by decreased reports of

pain, increased activity levels, and higher self-efficacy

expectations, and not by social support. Self-efficacy

expectations are important in the rehabilitation process and

are related to an internal attribution following treatment

gains. Findings of this study suggest that instructions in

the benefits of exercise and increased strength potentially

increased self-efficacy expectations and that following an

inability to experience a change with treatment

interventions, the patient's self-efficacy expectations

changed to an external reliance for help. These findings

suggest that patients who are encouraged to take an active

role in their rehabilitation adapt an internal attribution

for treatment success which is associated with actual

therapeutic gains. In contrast, patients who wait for

helpful treatment interventions may become more dependent on

others for help which potentially increases their

psychological distress and pain. Hence, the role of

internal locus of control (self-efficacy expectations) in

managing the chronic low back pain syndrome has important

implications for future improvements in performance and

disability.











In this study, treatment success was defined by

increased strength and decreased pain, and not by return to

work. This study attempted to focus on the specific effects

of exercise in the rehabilitation of chronic pain patients.

Studies addressing treatment outcome with return to work are

heavily weighted with socio-environmental influences and it

is therefore difficult to evaluate the beneficial treatment

components. In summary, exercise of the low back in a

chronic low back pain syndrome population is a necessary

treatment component, but it does not in and of itself,

ameliorate psychological distress or socio-environmental

influences. This implies that physical rehabilitation,

psychological rehabilitation, and return to work are

distinct areas of the treatment process and need to be

evaluated independently.

Limitations of the Study

This study examined the relationship between

psychological distress and exercise of the low back muscles

after twelve weeks of treatment in a chronic low back pain

syndrome population. Although subjects were randomized at

the beginning of treatment, the control group was found to

exhibit higher levels of psychological distress and

dysfunction pre-treatment. The finding of increased

psychological distress and pain in the control group as

compared to the treatment group may have been influenced by

these pre-treatment differences.











The subjects participating in this study exhibited a

chronic pain syndrome and this specific patient population

represents only a small portion of all individuals suffering

with chronic low back pain. Thus, these findings are

relevant only to patients with severe low back pain and

psychosocial dysfunction. Hence, a more heterogeneous

population with mild to moderate chronic low back pain who

were better psychologically and socially adjusted may have

exhibited different results.

This study only addressed one component of treatment

(exercise of the low back) in a chronic pain population and

compared changes in physical and psychological functioning

post-treatment with a wait-list control group. Other

important comparisons for investigation would have

potentially provided even more information regarding the

effectiveness of exercise in the treatment of chronic low

back pain. For example, an additional group engaged in a

commonly prescribed general exercise program for chronic low

back pain compared with MedXTM training might have been more

beneficial.

The subjects participating in this study were

significantly impaired in their ability to exercise through

a complete 72 degree range of motion. Performances on the

MedXT lumbar extension machine were highly variable and

group comparisons required statistical analysis for

standardizing the measuring points. Ideally, each subject











would have tested at the standard angles through the full

range of motion (0 to 72 degrees) and a standard

multivariate analysis of variance could have been utilized.

The examination of differing exercise regimens on the

MedXT lumbar extension machine would have also been

informative. Although previous research in healthy

individuals found that one exercise session per week was as

effective as two and three sessions per week, there is no

research addressing the effects of exercise frequency in a

chronic pain syndrome population (Graves et al., 1990). In

this study, all treatment subjects exercised twice a week

for six weeks followed by once a week for six weeks. Given

the chronicity of this samples disability, it can only be

speculated that exercise twice a week for the entire 12 week

treatment program may have resulted in even more dramatic

strength changes which may have potentially resulted in

beneficial changes in activities and psychological distress.

The current study demonstrated that the control group

increased in measures of pain and psychological distress

which suggests that the role of expectancy for getting

better may have influenced the outcome of the treatment and

control groups. The increased distress and pain evident in

the control group may have been a function of having to wait

for treatment. On the other hand, the increased pain and









87

psychological distress in the wait-list group may have been

a result of the continued lack of beneficial treatment

interventions.

Conclusions and Future Directions

This study found that after 14 exercise sessions on the

MedXT lumbar extension machine, a chronic low back pain

syndrome population significantly increased in measured

strength and decreased in reported pain. There were

significant changes found in physical and psychosocial

dysfunction post-treatment. Treatment gains were associated

with enhanced self-efficacy which has the potential for

positive impacts on future performance and disability.

Future research is needed to address the different

patient populations with chronic low back pain that would

benefit from exercise on the MedXTM lumbar extension

machine. Perhaps, patients with less physical and

psychosocial impairments would have experienced even greater

physical and psychological gains.

Given the chronicity of pain and deficits in physical

strength of this patient population, a treatment program

longer than 12 weeks may be necessary. A longer treatment

program may produce different results in terms of increases

in strength as well as increases in range of motion.

Additional research is needed to address the long-term

benefits of exercise on the MedXTM lumbar extension machine

in a chronic low back pain syndrome population. Future









88

research is currently under way to investigate the long-term

effects of exercise on the MedXTM lumbar extension machine

on psychological distress, return to work, and changes in

daily activities.

In conclusion, this study demonstrated that exercise on

the MedXT lumbar extension machine significantly

strengthened the low back extensor muscles in a population

of chronic low back pain syndrome patients. Associated

improvements were also found in the experience of pain and

physical and psychosocial dysfunction. Given that strength

changes with specific exercises of the extensor muscles have

been shown to increase strength in both healthy and low back

pain subjects, future research is needed to address the

potential benefits of this exercise modality on prevention

of future back injuries and the chronic low back pain

syndrome.















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Full Text
34
exercise include reducing pain, increasing strength,
decreasing mechanical stress on the spine, improving overall
physical fitness and preventing future injury, stabilizing
hypermobile spinal segments, improving posture, improving
mobility, and finally, recommending something "when all else
fails".
Although the role of exercise in chronic low back pain
is poorly understood, patients do improve following exercise
programs. For example, Manniche, Hesselsoe, Bentzen,
Christensen, and Lundberg (1988) reported significant
improvements in chronic back pain patients following two to
three months of exercise. Additionally, they found that
intensive exercise (multiple strengthening exercises for 1
1/2 hours for 30 sessions) was more effective than moderate
exercise (1/5 the intensity and time). In a large study of
the benefits of exercise conducted through the YMCA on
11,809 people, Kraus and Nagler (1983) reported on a
subsample of 546 post-surgical back pain patients that had
significant decreases in pain and increases in strength
following participation in a routine exercise program for
six weeks. Reilly, Lovejoy, Williams, and Roth (1989)
studied 40 males and females with chronic low back pain (10
each group) who were randomly assigned to a six month
supervised or home exercise program. They found that the
supervised exercise subjects were not only healthier, but
they had decreased their pain reports, had decreased their


4 DISCUSSION 70
Physiological Findings 72
Psychological Findings 74
Implications 80
Limitations of the Study 84
Conclusions and Future Directions 87
REFERENCES 89
APPENDICES 98
A PAIN QUESTIONNAIRE 98
B POST TREATMENT PATIENT QUESTIONNAIRE 105
BIOGRAPHICAL SKETCH 109
v


12
al. (1977) state, the patient's distress may be as important
as any structural damage in treating the chronic pain
patient. Treatments with a physical-psychological focus
often use operant conditioning principles that attempt to
extinguish pain behaviors by reinforcing "well behavior" and
ignoring "sick behavior." Within this treatment protocol,
there is a strong emphasis on increasing the patient's
physical activities (well behavior) and helping the patient
develop coping strategies which will lead to reductions in
sick behaviors (Block, 1982; Keefe & Gil, 1986; Turk, Wack,
& Kerns, 1985). This treatment approach endorses the notion
that chronic pain behaviors potentially come under the
control of environmental contingencies. For example, if
pain is experienced following the lifting of a heavy object,
avoiding lifting that object will decrease the pain
(respondent conditioning). With the continued avoidance of
lifting the heavy object, the behavioral changes become
operant in nature and may generalize to lifting all objects
or even to the entire work place. A reinforcement
contingency then develops in the absence of the original
pain-eliciting event. Hence, the individual generalizes
pain behaviors to other situations. A secondary
reinforcement contingency may also develop from potential
positive reinforcement received by others deriving from
their changed pain behavior patterns (operant conditioning)
(Bono & Zasa, 1988). The operant treatment approach,


38
will have a low work endurance ability and are therefore at
high risk for injury to the low back (Jones et al., 1988).
Additionally, these investigators suggest that current
inodes of exercising these muscle groups are ineffective in
that the hip extensors (legs and buttocks muscles)
predominate and interfere with the strengthening of the
lumbar extensor muscles. Exercise on the MedX lumbar
extension machine is proposed to be a superior exercise
modality in that the pelvis and large thigh and gluteal
muscles are restrained and stabilized which isolates the
lumbar extensors for maximum exercise benefits. Studies
utilizing the MedX lumbar extension machine have found
that normal subjects trained on the MedX lumbar extension
machine have significant increases in low back strength,
despite their previous exercise experience (Pollock,
Leggett, Graves et al., 1989). Hence, Jones et al. (1988)
propose that these muscle groups must be isolated and
exercised in order to increase their strength and thereby
reduce the risk of low back injuries. They conclude further
that routine exercise on the MedX lumbar extension machine
is the only available method which isolates and strengthens
the lumbar extensor muscles.
There is currently only one study addressing the
benefits of MedX training for individuals with low back
pain. This study examined a population of 12 mild low back
pain subjects who exercised on the MedX lumbar extension


methods of treating their pain. All subjects were re-tested
on the psychological questionnaires and re-tested for
isometric strength on the MedX at the end of 12 weeks.
Multivariate analysis of covariance of change scores
revealed that the treatment group significantly improved in
strength as compared to the control group. Increased
strength was associated with a significant decrease in pain
and in physical and psychosocial dysfunction. In contrast,
the control group increased in reported pain and perceived
physical and psychosocial dysfunction. There were no
significant differences between groups on measures of
depression, anxiety, and stress.
Pre-treatment measures indicated that both groups
reported high levels of self-efficacy (internal locus of
control) prior to entering the treatment protocol, but post
treatment analysis indicated that the control group changed
to decreased self-efficacy expectations (an external locus
of control). The treatment group maintained a high self-
efficacy rating post-treatment.
The findings of this study support the hypothesis that
exercise on the MedX machine is a beneficial treatment for
chronic low back pain patients. There is evidence that
increasing the strength of the low back muscles decreases
pain and improves physical and psychosocial functioning.
Self-efficacy expectations were significantly related to
treatment gains.
viii


LIST OF TABLES
TABLE PAGE
TABLE I SUBJECT CHARACTERISTICS OF THE
WAIT-LIST CONTROL AND TREATMENT
GROUPS STUDIED FOR EFFECTS OF
EXERCISE OF THE LOW BACK MUSCLES 57
TABLE II PHYSIOLOGICAL MEASURES 62
TABLE III PSYCHOLOGICAL DYSFUNCTION AND PAIN
PRE/POST-TREATMENT MEANS AND
STANDARD DEVIATIONS 64
TABLE IV MULTIPLE REGRESSION OF THE RELATIONSHIP
OF PRE-TREATMENT PSYCHOLOGICAL
VARIABLES TO POST-TREATMENT INTERCEPT
VALUES 68
TABLE V CORRELATION ANALYSIS OF STRENGTH CHANGES
(CHANGES IN INTERCEPT SCORES PRE/POST
TREATMENT) AND POST-TREATMENT
PSYCHOLOGICAL MEASURES 69
Vi


TABLE V
CORRELATION ANALYSIS OF STRENGTH CHANGES
(CHANGES IN INTERCEPT SCORES PRE/POST-TREATMENT)
AND POST-TREATMENT PSYCHOLOGICAL MEASURES
VARIABLE 12 3 4 5 6 7 8 9 10 11
1. INTERCEPT
CHANGE SCORES
2. PHYSICAL
DYSFUNCTION -.56**
3. PSYCHOSOCIAL
DYSFUNCTION -.46** .84**
4. PAIN
POST
TREATMENT -.39** .68** .67**
5. HOURS IN
PAIN
-.34*'
' .65**
.64**
.72**
6. PAIN
CHANGE SCORE
. 04^
.21
.20
.42**
281.
7. DISTRESS
-.30*
.65**
.84**
.63**
.48**
.12
8. WELL
BEING
. 13
-.40**-
.64**
-.56**
-.40**
-.10
-.83**
9. STRESS
-.25
.54**
.68**
.67**
.44**
.18
.88**
-.78**
10.INTERNAL
LOC
.34*'
'-.63**-
.67**
-.53**
-.41**
-.26
-.57**
.39**
-.54**
11.EXTERNAL
LOC
.04
.18
.23
. 10
.02
.21
.21
-.09
.19
-.38**
12.NEGATIVE
SUPPORT
.02
.14
.38**
.23
.26
-.02
.40**
-.40
.24
-.13
-.03
13.POSITIVE
SUPPORT
. 03
. 13
.01
.13
.06
.07
-.02
. 09
.05
-.27
. 19
12
-.40
* E < 0.05
** E < 0.01
CTi
VO


25
the groups pre-treatment in avoidance behaviors or negative
perceptions, but at post-treatment there was a significant
difference. The treatment group reported significantly
higher levels of self-control over their pain (increased
self-efficacy) and perceived their pain as less of a problem
when compared to the wait-list control group. Hence, in
this study, learning coping strategies in therapy increased
their self-efficacy expectancies, enhanced their ability to
function, and decreased their negative perceptions of their
pain problem (Philips, 1987).
Dolce and colleagues (1986) reported several studies
addressing the role of setting quotas of performance,
feelings of mastery at different levels, and subsequent
self-efficacy ratings for future performance. They reported
a laboratory study in which 64 college undergraduates
participated in an experimental pain procedure (cold pressor
test). These subjects were asked to rate their self-
efficacy expectations on their ability to tolerate
increasing levels of pain. These investigators found that
setting systematic quotas for pain tolerance increased the
subject's ability to tolerate pain. In addition, there was
a significant correlation between self-efficacy expectancies
and actual pain tolerance. Of note, a group that took a
placebo medication supposedly to improve pain tolerance
actually decreased in pain tolerance. These authors
concluded that setting quotas was more beneficial than


8
researchers have studied pain with psychophysical
definitions of pain threshold levels, with intensity
ratings, with magnitude estimations (utilizing cross
modality matching scales for intensity and quality of pain),
and with observable behaviors for discrimination and
detection of pain (Chapman, Casey, Dubner, Foley, Gracely &
Reading, 1985). Additionally, chronic pain has been
described as a psychobiological disorder; as a symptom in
which pain fulfills the needs of a dysfunctional family
system; as a classical conditioning paradigm or respondent
model of pain in which a pain-tension cycle is created; as
an operant model where the pain is believed to be under the
control of contingencies of reinforcement; and finally, as a
diathesis stress model where physical, psychological and
social factors are believed to have preconditioned the
patient for hyper-reactivity with a responsive stereotypic
style (diathesis) resulting from a genetic predisposition
(Chaturvedi, Varma & Malhotra, 1984; Turk & Kerns 1984).
Theories of pain sensation and sensitivity are
beneficial in explaining the nociception of experimentally
induced pain, but they fall short in describing the clinical
patient presenting with the chronic pain syndrome.
Laboratory studies have successfully documented the role of
endogenous opioids and cognitive mediational processes in
the control of pain (Bandura et al., 1987; Yang, Richlin,
Brand, Wagner, & Clark, 1985), but as mentioned earlier,


83
and socio-environmental factors for the successful
rehabilitation of the chronic low back pain syndrome
patient.
Treatment success was predicted by decreased reports of
pain, increased activity levels, and higher self-efficacy
expectations, and not by social support. Self-efficacy
expectations are important in the rehabilitation process and
are related to an internal attribution following treatment
gains. Findings of this study suggest that instructions in
the benefits of exercise and increased strength potentially
increased self-efficacy expectations and that following an
inability to experience a change with treatment
interventions, the patient's self-efficacy expectations
changed to an external reliance for help. These findings
suggest that patients who are encouraged to take an active
role in their rehabilitation adapt an internal attribution
for treatment success which is associated with actual
therapeutic gains. In contrast, patients who wait for
helpful treatment interventions may become more dependent on
others for help which potentially increases their
psychological distress and pain. Hence, the role of
internal locus of control (self-efficacy expectations) in
managing the chronic low back pain syndrome has important
implications for future improvements in performance and
disability.


31
findings for the psychological benefits of exercise, Hughes,
Casal, and Leon (1986) studied sedentary men assigned to an
exercise or a control condition. These authors found no
psychological benefits (such as reduced anger, depression,
or mood disturbance) derived from the exercise condition
when compared to controls. Another study confirmed these
findings with adult women. These women participated in an
exercise program and were compared to a no-exercise control
group. Again, no psychological benefits were found
(Coleman, Price & Washington, 1985).
In contrast, aerobic and anaerobic exercise have been
reported as beneficial in elevating mood states, improving
self-concept, and decreasing anxiety (Folkins & Sime, 1981;
Reiter, 1981; Sime, 1984). For example, Doyne Ossip-Klein,
Bowman et al. (1987) studied 40 depressed females and found
that both aerobic and anaerobic exercise significantly
decreased depression compared to a wait-list control group.
There were no differences found between the two types of
exercise, and treatment gains were maintained for both
groups at a one year follow-up.
These inconsistent findings suggest that the initial
level of psychological distress (anxiety, depression, or
self-esteem) is an important factor when exercise produces
psychological benefits. For example, low self-esteem
appears to improve following exercise, but the studies
looking at self-esteem only find changes if initial self-


104
g.How many different drugs have you taken in the last month?
1. Name the first drug
How many days a week do you take this drug?
How many time a day do you take it?
2. Name the second drug
How many days a week do you take this drug?
How many time a day do you take it?
3. Name the third drug
How many days a week do you take this drug?
How many time a day do you take it?
4. Name the fourth drug
How many days a week do you take this drug?
How many time a day do you take it?
5. Name the fifth drug
How many days a week do you take this drug?
How many time a day do you take it?
6. Name the sixth drug
How many days a week do you take this drug?
How many time a day do you take it?
7. Name the seventh drug
How many days a week do you take this drug?
How many time a day do you take it?
8. Name the eighth drug
How many days a week do you take this drug?
How many time a day do you take it?


96
Schuchmann, J.A. (1988). Low back pain: A comprehensive
approach. Comprehensive Therapy. 14, 14-18.
Sime, W.E. (1984). Psychological benefits of exercise
training in the healthy individual. In J.D. Matarazzo,
S.M. Weiss, J.A. Herd, N.E. Miller, and S.M. Weiss
(Eds.), Behavioral Health: A Handbook of Health
Enhancement and Disease Prevention (pp.488-508). New
York: John Wiley and Sons.
Smidt, G., Herring, T., Amundsen, L., Rogers, M., Russell,
A., and Lehmann, T. (1983). Assessment of abdominal and
back extensor function. A quantitative approach and
results for chronic low back patients. Spine. 8, 211-
219.
Snook, S.H. and Webster, B.S. (1987). The cost of
disability. Clinical Orthopaedics and Related Research.
221. 77-84.
Spanos, N.P., Perlini, A.H., and Robertson, L.A. (1989).
Hypnosis, suggestion, and placebo in the reduction of
experimental pain. Journal of Abnormal Psychology. 98,
285-293.
Sternbach, R.A. (1974). Pain patients: Traits and treatment.
New York: Academic Press.
Sternbach, R.A. and Tursky, B. (1965). Ethnic differences
among housewives in psychophysical and skin potential
responses to electric shock. Psychophysiology. 1, 241-
246.
Tan, Siang-Yang. (1982). Cognitive and cognitive-behavioral
methods for pain control: A selective review. Pain. 12,
201-228.
Taylor, J. (1989). The effects of personal and competitive
self-efficacy and differential outcome feedback on
subsequent self-efficacy and performance. Cognitive
Therapy and Research. 13, 67-79.
Tollison, C.D., Driegel, M.L., and Satterthwait, J.R.
(1989). An adjunctive exercise technique for painful
extremities. Pain Management. 2, 215-216.
Turk, D.C. and Flor, H. (1984). Etiological theories and
treatments for chronic back pain, II. Psychological
models and interventions. Pain. 19, 209-233.


81
findings of this study have potential implications for the
severely disabled low back pain population as well as the
less disabled back pain patient as is typically found in
out-patient treatment programs. Of particular interest is
the fact that those who suffer with significantly high
levels of psychological distress and physical disabilities
exhibit beneficial changes with lumbar extension exercise.
This would suggest that a less severely disabled group might
demonstrate greater therapeutic gains with low back exercise
because of lower levels of pre-treatment pain and
psychological distress. However, the improvements found in
this chronic pain syndrome population may have been greater
given the high levels of dysfunction.
In addition to increased strength with exercise on the
MedX lumbar extension machine, patients reported less pain
post-treatment. Decreased pain reports are important in
that it is the subjective experience of pain that results in
patients seeking health care services and it is the report
of pain that often determines treatment interventions
(Kleinke & Spangler, 1988). Hence, exercise and increased
strength of low back muscles reduces reported pain and has
the potential for a reduction in the over utilization of the
health care system associated with this population.
Although exercise on the MedX lumbar extension machine did
not result in reported increased activity levels, there was
a decline in perceived physical and psychosocial


5
psychological experiences (Bandura, O'Leary, Taylor,
Gauthier, & Gossard, 1987; Craig, 1983; Turk, Meichenbaum, &
Genest, 1983; Weisenberg, 1977).
An often-cited theory of pain is Melzack and Wall's
(1965) Gate Control Theory. This theory postulates a
neurophysiological basis for the role of psychological
factors in the pain experience. It describes the
interaction between sensory-discriminative, affective-
motivational, and cognitive-evaluative systems (Turk & Flor,
1984; Turskey et al., 1982; Melzack & Dennis, 1978). The
model incorporates the importance of psychological factors
in the central nervous system's modulation of pain. The
perception of pain is said to be influenced by the
individual's attitudes and attentions which act through a
central control mechanism. The control mechanism operates
via descending neural fibers which modulate the excitation
of afferent pain receptors in the dorsal horn of the spinal
column. Opening and closing of this control mechanism
increases or decreases sensory sensitivity. In summary,
suffering with pain is correlated with psychological states
that exacerbate the neurophysiological mechanisms (Clark &
Yang, 1983; Melzack & Dennis, 1978; Turk & Flor, 1984;
Tursky et al., 1982).
In support of this model of pain, experimental studies
have shown that reported pain severity and reactions to pain
are related to cultural variables (Sternbach & Tursky,


CHAPTER 1
INTRODUCTION
The importance of rehabilitating patients with low back
pain is evident from reports which estimate that 80% of the
general population and 85% of the industrial population will
at some time experience low back pain (Feuerstein, Papciak,
& Hoon, 1987; Mayer, Gatchel, Kishino et al., 1986;
Rosomoff, 1985; Schuchmann, 1988). More specifically, this
disabling condition has partially disabled five million
people in the United States and accounts for approximately
93 million lost work days resulting in a sixteen billion
dollar economic loss each year (Block, 1982; Snook &
Webster, 1987).
Low back pain is commonly associated with injuries of
the nerves, bone, joint or ligaments, with resulting
myofacial syndromes and degenerative diseases of the spine
(Feuerstein et al., 1987). Of note, a high percent of the
patients with low back pain appear to suffer from soft
tissue injury in the lumbar spine area, with 78% of disabled
low back pain patients having no demonstrable
pathophysiological basis for their pain (Bono & Zasa, 1988;
Loeser, 1980; Mayer et al., 1986). Thus, treatment of the
1


66
In order to assess pre-treatment predictors of
therapeutic gain, the five variables measuring positive
support, pain, past week activity levels, and internal or
external locus of control were entered into a stepwise
regression model with post-treatment intercepts as the
dependent variable. The regression analysis indicated that
28% of the variance was attributable to pre-treatment
measures of the past weeks activity level, pain, and
external locus of control (F(3,52)=6.22, p < 0.001). The
relationship between pre-treatment pain and post-treatment
intercepts accounted for 19% of the total variance in the
model and was the only significant variable influencing
strength outcome [F(4,48)=4.81, p < 0.002). (See Table IV.)
In order to assess the relationship between physical
strength changes, self-reported pain, and psychological
distress, a Pearson's correlational analysis was performed
looking at pre/post-treatment intercept change scores and
post-treatment psychological measures. Results indicated
that increased strength was positively correlated with an
internal locus of control (r=0.34, p<0.01), and negatively
correlated with higher levels of dysfunction on the physical
and psychosocial impact scales of SIP (r=-0.56, p<0.0001 and
r=-0.45, p<0.0006, respectively), with higher pain reports
(r=-0.39, p<0.004), and with increased psychological
distress on the MHI (r=-0.30, p<0.03). On the other hand,
high reports of pain post-treatment were not only negatively


75
treatment group reported less physical and psychosocial
disruption while the control group reported more
impairments. This measure of impairment covers a broad
array of physical, emotional, and social situations in which
illness behaviors have a negative impact. As is evident in
the correlational analysis, the two subscales are highly
correlated and therefore, it is not surprising that finding
a change in one subscale resulted in a change in the other.
Interestingly, there were no concomitant changes found in
weekly activity levels, depression and anxiety, or stress.
These findings may be indicative of the sensitivity of the
measuring instrument, or that perceived increased physical
abilities does not readily result in increased activities.
Additionally, global measures of psychosocial functioning
may change more rapidly than more specific measures of
depression, anxiety, and stress.
The subjects participating in this study experienced
high pre-treatment levels of depression, anxiety, and stress
as measured by the Mental Health Inventory and Perceived
Stress Survey. Pre-treatment scores on the Sickness Impact
Profile were also significantly elevated. Of concern is
that the control group generally reported higher levels of
psychological distress pre-treatment as compared to the
treatment group. In addition, the control group was found
to have been unemployed due to pain for a longer duration of
time than the treatment group. It might be speculated that


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TORQUE
250
ANGLE
PRE-TREAT POST-TREAT
PRE-CONTROL -b- POST-CONTROL
FIGURE II
PRE-POST TREATMENT TORQUE
(REGRESSED MEANS RANGING FROM 0 TO 60 DEGREES)


44
Equipment and Measures
MedX Assessment and Training
MedX testing consisted of an isometric test of lumbar
extension strength at seven different testing points within
each subjects range of motion up to a maximum arch of 72
degrees. Subjects were seated in the MedX lumbar
extension machine and their knees were positioned so that
their femurs were parallel to the seat. Subjects were
secured in place by specially designed femur and thigh
restraints used to stabilize the pelvis. To begin the test,
subjects were locked into between 48 and 72 degrees of
flexion and instructed to extend their back against the
upper back pad. Once maximal tension had been achieved, the
subjects were instructed to maintain a maximal contraction
for one to two seconds before relaxing. A 10 second rest
interval was provided between each isometric contraction
while the next angle of measurement was set. During the
contractions, the subjects were provided visual feedback of
their generated force and were verbally encouraged to give a
maximum effort. A maximum isometric contraction was
measured at each of the seven angles and a computerized
force curve was obtained. The subject then exercised
through flexion and extension with a work load of 1/2 their
peak isometric strength until fatigued. At this point, a
second force curve was generated. The shape of the two
force curves were noted for similarity and the difference


77
chronicity of pain and the associated socio-environmental
influences was beyond the scope of this study, but these
factors surely play a significant role in the maintenance of
psychological distress. Hence, distress potentially
associated with socio-environmental factors would not be
expected to respond to an intervention of exercise, but
would require interventions aimed at ameliorating the
distressing situations. In summary, exercise on the MedX
lumbar extension machine improved low back strength, but did
not result in significant decreases in depression, anxiety,
and stress in this patient population.
After addressing the effects of exercise on self-
reported pain, this study found that the treatment group
decreased their pain reports while the control group
increased their report of pain. There were no pre-treatment
differences in reported pain. Hence, these findings lend
support to the hypothesis that patients with low back pain
may avoid activities that previously created pain which
results in muscular disuse and atrophy. Atrophied muscles
potentially increase pain independent of the original pain
stimuli (Feuerstein et al., 1987; Rosomoff, 1985). In
summary, exercise of the low back muscles resulted in lower
levels of reported pain in the treatment group while the
control group's report of pain continued to escalate.
An important element of this study addressed the role
of self-efficacy in treatment adherence and outcome. There


62
TABLE II
PHYSIOLOGICAL MEASURES
TREATMENT GROUP CONTROL GROUP
PRE/POST TREATMENT PRE/POST TREATMENT STATISTIC
(STANDARD DEVIATION) (STANDARD DEVIATION) P VALUE
MEAN
INTERCEPT
73.2
(45.1)
104.1
(63.5)
73.4
(54.6)
73.6
(58.8)
F(2,52)=6.50
E<0.01
MEAN
SLOPE
1.4
(0.8)
1.4
(0.7)
1.9
(1.1)
1.7
(0.9)
ns
MEAN TORQUE AT SEVEN STANDARD
ANGLES IN DEGREES:
ANGLE 0
70.9
(43.9)
(N=31)
100.7
(63.4)
(N=31)
74.0
(54.5)
(N=2 3)
72.2
(58.7)
(N=23)
F(2,51)=6.89
E<0.01
ANGLE 12
91.2
(47.3)
(N=31)
123.5
(64.5)
(N=31)
96.5
(60.6)
(N=23)
94.1
(56.5)
(N=23)
F(2,51)=9.46
E<0.003
ANGLE 24
108.9
(51.4)
(N=31)
140.9
(67.2)
(N=31)
121.7
(68.8)
(N=23)
116.6
(57.9)
(N=23)
F(2,51)=10.93
E<0.002
ANGLE 36
129.1
(55.0)
(N=30)
158.4
(69.9)
(N=31)
149.1
(77.2)
(N=22)
139.6
(61.5)
(N=22)
F (2,48)=10.17
E<0.002
ANGLE 48
143.2
(63.1)
(N=28)
177.0
(74.6)
(N=29)
160.2
(86.1)
(N=17)
162.3
(66.7)
(N=19)
F (2,41)=5.38
E<0.02
ANGLE 60
157.9
(73.9)
(N=23)
193.3
(82.5)
(N=27)
195.5
(100.3)
(N=12)
173.6
(67.0)
(N=12)
F(2,31)=13.77
E<0.0008
ANGLE 72
170.3
(67.8)
(N=9)
211.5
(68.6)
(N=12)
148.5
(59.4)
(N=4)
156.4
(62.2)
(N=5)
F(2,10)=7.53
E<0.02


95
McCready, M., and Long, B. (1985). Exercise adherence.
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Melzack, R. (1983). Pain Measurement and Assessment.
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Philips, H.C. (1987). Avoidance behavior and its role in
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Rosomoff, H.L. (1985). Do herniated disks produce pain?
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Roth, D.L. and Holmes, D.S. (1985). Influence of physical
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ACKNOWLEDGEMENTS
I wish to express my appreciation and thanks to my
chairperson, Nancy Norvell, for working with me on this
study and affording me the opportunity to complete it under
her supervision. Most importantly, I appreciate her
continued support and her contributions of advice and
expertise in this study's formulation and completion. In
addition, a special thanks are extended to my committee
members, Michael Robinson, Anthony Greene, James Johnson,
and Michael Pollock, for their support and supervision in
this dissertation preparation. I also extend my thanks and
gratitude to the staff of E. David Risch and to the staff of
the Center for Exercise Science for their assistance in the
completion of this treatment study. Mostly, a special
thanks are extended to my husband and children for their
support and understanding while I worked on this
dissertation. Without their love and reassurance, I could
not have persevered in completing this work.
iii


94
Levine, M.E. (1971). Depression, back pain, and disc
protrusion. Diseases of the Nervous System. 32., 41-45.
Linton, S.J. (1987). Chronic pain: The case for prevention.
Behavior Research and Therapy. 25, 313-317.
Litt, M.D. (1988). Self-efficacy and perceived control:
Cognitive mediators of pain tolerance. Journal of
Personality and Social Psychology. 54, 149-160.
Loeser, J.D. (1980). Low Back Pain. In J.J. Bonica (Ed.),
Pain. New York: Raven Press.
MacMillan, M., Pollock, M.L., Graves, J.E., Leggett, S.H,
and Fulton, M.N. (1988). Effect of lumbar extensor
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patients with mild chronic low back pain, (unpublished
data).
Manniche, C., Hesselsoe, G., Bentzen, L., Christensen, I.,
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Manning, M.M. and Wright, T.L. (1983). Self-efficacy
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Mayer, T.G., Gatchel, R.J., Kishino, N., Keeley, J., Capra,
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Quantification of lumbar function part 2: sagittal plane
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91
Dolce, J.J., Crocker, M.F., and Doleys, D.M. (1986).
Prediction of outcome among chronic pain patients.
Behavior Research and Therapy. 24. 313-319.
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Dolce, J.J., Doleys, D.M., Raczynski, J.M., Lossie, J.,
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Environmental stressors and chronic low back pain: Life
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Archives of Physical Medicine and Rehabilitation. 53.,
503-508.


85
The subjects participating in this study exhibited a
chronic pain syndrome and this specific patient population
represents only a small portion of all individuals suffering
with chronic low back pain. Thus, these findings are
relevant only to patients with severe low back pain and
psychosocial dysfunction. Hence, a more heterogeneous
population with mild to moderate chronic low back pain who
were better psychologically and socially adjusted may have
exhibited different results.
This study only addressed one component of treatment
(exercise of the low back) in a chronic pain population and
compared changes in physical and psychological functioning
post-treatment with a wait-list control group. Other
important comparisons for investigation would have
potentially provided even more information regarding the
effectiveness of exercise in the treatment of chronic low
back pain. For example, an additional group engaged in a
commonly prescribed general exercise program for chronic low
back pain compared with MedX training might have been more
beneficial.
The subjects participating in this study were
significantly impaired in their ability to exercise through
a complete 72 degree range of motion. Performances on the
MedX lumbar extension machine were highly variable and
group comparisons required statistical analysis for
standardizing the measuring points. Ideally, each subject


23
that patients exhibiting high levels of pain behavior and
reporting high levels of pain preferred to have an inactive
role in treatment (e.g., passive therapies such as ice or
heat packs) whereas patients with less pain behavior and
lower self-reported pain chose to take an active role in
their rehabilitation in the form of active physical
exercise.
Manning and Wright (1983) evaluated self-efficacy
expectancies (e.g., perceived ability to undergo childbirth
without the use of medication) in 52 pregnant women. Self-
efficacy expectations were found to predict persistence in
self-controlled pain during labor in that higher self-
efficacy ratings were correlated with decreased medication
usage. Of note, this finding was independent of the length
of time the subject experienced labor pain. These authors
concluded that self-efficacy expectations were a better
predictor of outcome (i.e., decreased pain complaints) than
were previously exhibited behaviors (e.g., behaviors during
child birth classes).
Holroyd, Penzien, Hursey et al. (1984) studied the role
of self-efficacy expectations in the control of tension
headaches. These authors recruited 43 recurrent tension
headache subjects from a college population for an
electromyography (EMG) biofeedback treatment study. This
study utilized a 2 x 2 factorial design in which subjects
were randomly assigned to one of four conditions. Treatment


99
6. Marital History:
Married Separated Widowed
Not married but
living together Divorced Single
7. Employment Status:
a. Have you ever been employed? Yes ( ) No ( )
b. What is your present employment status?
Employed full time ( ) Unable to work
due to other illness ( )
Employed part-time ( ) Homemaker ( )
Self-employed ( ) Student ( )
Looking for work ( ) Retired ( )
Unable to work due
to back or leg pain( ) Other ( )
c.What is your present or most recent occupation?
d.How long has it been since you last worked?
(Please write in amount of time)
Years Months Weeks
8.Family income:
a. What was your total household income from all sources
for the past year?
$ 0,000 9,999
$ 10,000 19,999
$ 20,000 34,999
$ 35,000 49,999
$ 50,000 +
b.Are you presently the primary earner in your household?
Yes ( )


9
there is a lack of understanding between chronic pain and
the chronic pain syndrome (Bigos & Battie, 1987). Hence,
theories of pain that incorporate psychological, physical,
and environmental influences are more proficient at
explaining the chronic pain experience.
In summary, there are many models and explanations of
acute and chronic pain experience, most of which include
psychological and social phenomena as a prominent factor.
Therefore, a biopsychosocial conceptualization of chronic
pain (which incorporates the role of physiological,
social/environmental, and psychological responses) is viewed
as the predominant working model (Waddell, 1987).
Treatment of Chronic Pain
Interventions and treatment of the chronic pain patient
vary depending on the practitioner's theoretical formulation
of the chronic pain syndrome. Traditionally, medical
treatments have consisted of conservative management which
included bed rest, traction and medication, or surgical
interventions. Unfortunately, these treatment modalities do
not appear to resolve the pain for a significant majority of
chronic pain patients. For example, short-term pain relief
often follows surgery, but for some patients, surgery does
not provide long-term pain relief. Gottlieb et al. (1977)
cited unpublished data by Shealy and Beckner (1975) stating
that 30% of the patients undergoing a traditional
neurosurgical procedure failed to experience post-operative


100
c.Are you presently receiving money from unemployment?
Yes ( )
d.Are you presently receiving money from workmen's comp?
Yes ( )
e.Are you presently receiving money from social security?
Yes ( )
f.Other
9. Litigation status:
a.Have you ever been involved in any legal action
(already settled) related to your pain?
Yes ( ) No ( )
b.
Are you currently involved in any legal action for
your pain?
Yes ( ) No ( )
10. Pain Evaluation:
a. How long has it been since you first had any kind of
low back pain? (Please write in the amount of time)
Years Months Weeks
b. How long have you had the low back pain for which you
are now seeking treatment? (Please write in the amount
of time)
Years Months Weeks
c. Did this pain begin suddenly or gradually?
Suddenly Gradually
d. What do you believe is the reason for the onset of
your present pain?
Accident or injury Being overweight
Car Accident Emotional Stress
Illness or disease Pregnancy
Surgery Work Accident
Don't know Lifting/turning
Other


76
the control group reported higher levels of psychological
distress in response to their less stable economic and
social situation as a result of longer durations of
unemployment. This is only speculative, but given that
physical findings, activities, pain behaviors, and pain
report were not significantly different between the groups
pre-treatment, it appears to be a reasonable hypothesis.
Analysis of differences in measures of depression,
anxiety, and stress indicated no differences between groups
at the end of the treatment study. These psychological
measures of distress were significantly elevated pre
treatment for both groups and remained high over the 12 week
study. Studies addressing the effects of exercise on
depression and anxiety have found that mild to moderately
elevated distress appears to improve with exercise, not
severe elevations of distress (Sinyor et al., 1983). Hence,
the level of psychological distress in this study's
population was sufficiently high that more intensive
interventions may be needed to specifically address these
patients' depression, anxiety, and stress. Additionally, as
was noted in the pre-treatment analysis, the subjects
participating in this study experienced pain for extended
durations of time, were out of work for long time periods,
and half of the sample were dependent on disability or
workmen's compensation for their primary source of income.
The impact on psychological well-being of increased


.nvrIE.&orida
3 1262 08554 5951


40
Hypotheses
The literature reviewed suggests that physical
reconditioning is important in treating patients with
chronic low back pain, particularly in order to recondition
specific atrophied muscles. The chronic back pain patient
avoids activity in an attempt to decrease pain which in
turn, may result in increased pain and psychological
distress. Feuerstein et al. (1987) suggested that
strengthening the muscles of the low back and lower
extremities is an important correlate of improvement after
treatment in the chronic low back pain patient, but this
area of investigation has been neglected. While many
treatment programs for the chronic pain patient include
physical and psychological components, the specific effects
of physical reconditioning on functional and psychological
outcomes are poorly understood.
Jones et al. (1988) propose that the MedX lumbar
extension machine has the ability to isolate and strengthen
the weaker extensor muscles of the low back in healthy
subjects and subjects with mild low back pain. The meaning
of the previous research with mild low back pain patients is
unclear in that there is no differentiation of mild with
respect to mild physical or mild psychological involvement.
In summary, there has been no research to date investigating
this machine as a treatment modality for a diverse chronic
low back pain population.


APPENDIX A
PAIN QUESTIONNAIRE
Study #.
1.Name:
Last First Middle/maiden
2. Sex: Male ( ) Female ( )
3. Date of birth: Month Day Year
4. Ethnic Background:
White Black American Indian
Asian
Hispanic other
5.Educational Background:
Grade School
1
2
3
4 5 6 7
High School
9 10
11
12
College
1 2
3
4
Degree
Graduate
Some
(
)
Completed
GED
Yes
(
)
Vocational
School
Yes
(
)
98


16
patient receiving a final disability determination at the
end of treatment. Differences in treatment responsivity and
sample characteristics in different treatment settings were
documented in a study by Deyo, Bass, Walsh, Schoenfeld and
Ramamurthy (1988). These investigators recruited subjects
for a clinical treatment of low back pain by advertising for
an outpatient treatment program (clinical group), and they
recruited another sample of subjects with low back pain in a
multidisciplinary pain clinic. Although the two groups of
subjects did not differ on duration or intensity of pain,
there were significant differences found between the groups
pre- and post-treatment. The clinical outpatient group was
more likely to be working, using no medication, having
higher incomes and education, and not receiving workmen's
compensation pre-treatment. Additionally, post-treatment
findings indicated that the clinical group significantly
benefited more from treatment compared to the
multidisciplinary treatment group. Hence, the authors
suggested that patients participating in multidisciplinary
treatment programs tend to represent a small, specific
sample who experience not only chronic pain, but have lower
incomes and education and are more reliant on insurance and
work related compensations which impacts on treatment
outcome (Deyo et al., 1988).
Another problem in this area of research is that few
experimental studies have been conducted which examine the


CHAPTER 2
METHOD
Subjects
Fifty-five subjects (34 males and 21 females) were
referred for rehabilitation on the MedX lumbar extension
machine by an orthopaedic surgeon specializing in disorders
of the spine. The average age of the subjects was 45 years
(ranging from 22 to 70 years). The sample was predominantly
Caucasian (91%) and married (76%). Subjects experienced low
back pain for an average of eight years (ranging from 1 to
26 years), had two surgeries or less, were ambulatory, and
were not dependent (daily use) on narcotic analgesics.
Fifty-four percent of the subjects were receiving workmen's
compensation or disability payments as their primary source
of income and the average time out of work due to pain was
37 months (ranging from 0 to 168 months). Thirty-five
percent of the subjects were employed full-time and 46% were
unemployed due to back pain. The onset of pain was
described as sudden and was related to an automobile or work
accident for 83% of the sample.
43


I certify that I have read this study and that in my
opinion it conforms to acceptable standards of scholarly
presentation and is fully adequate, in scope and quality, as
a dissertation for the degree of Doctor of Philosophy.
Michael Robinson
Assistant Professor of
Clinical and Health Psychology
I certify that I have read this study and that in my
opinion it conforms to acceptable standards of scholarly
presentation and is fully adequate, in scope and quality, as
a dissertation for the degree of Doctor of Philosophy.
Michael L. Pollock
Professor of
Exercise and Sports Sciences
This dissertation was submitted to the Graduate Faculty
of the College of Health Related Professions and to the
Graduate School and was accepted as partial fulfillment of
the requirements for the degree of Doctor of Philosophy.
Dean, College of Health Related
Professions
Dean, Graduate School
May 1990


92
Folkins, C.H. and Sime, W.E. (1981). Physical fitness
training and mental health. American Psychologist. 36,
373-389.
Follick, M.J., Smith, T.W., and Ahern, D.K. (1985). The
sickness impact profile: A global measure of disability
in chronic low back pain. Pain. 21, 67-76.
Fordyce, W.E. (1988). Pain and suffering. American
Psychologist. 43. 276-283.
Fredrickson, B.E., Trief, P.M., VanBeveren, P., Yuan, H.A.,
and Baum, G. (1988) Rehabilitation of the patient with
chronic back pain: A search for outcome predictors.
Spine. 13, 351-353.
Gatchel, R.J., Mayer, T.G., Capra, P., Barnett, J., and
Diamond, P. (1986). Milln Behavioral Health Inventory:
Its utility in predicting physical function in patients
with low back pain. Archives of Physical Medicine
Rehabilitation. 67, 878-882.
Gatchel, R.J., Mayer, T.G., Capra, P., Diamond, P., and
Barnett, J. (1986). Quantification of lumbar function
part 6: the use of psychological measures in guiding
physical functional restoration. Spine. 11. 36-42.
Gottlieb, H., Strite, L.C., Roller, R., Madorsky, A.,
Hockersmith, V., Kleeman, M., and Wagner, J. (1977).
Comprehensive rehabilitation of patients having chronic
low back pain. Archives of Physical Medical
Rehabilitation. 58, 101-108.
Graves, J.E., Pollock, M.L., Foster, D., Leggett, S.H.,
Carpenter, D.M., Vuoso, R., and Jones, A. (1990). Effect
of training freguency and specificity on isometric lumbar
extension strength. Spine. In Press.
Hazard, R.G., Fenwick, J.W., Kalisch, S.M., Redmond, J.,
Reeves, V., Reid, S., and Frymoyer, J.W. (1989).
Functional restoration with behavioral support: A one
year prospective study of patients with chronic low back
pain. Spine. 14, 157-161.
Heinrich, R., Cohen, M., Naliboff, B., Collins, G., and
Bonebakker, A. (1985). Comparing physical and behavior
therapy for chronic low back pain on physical
abilities, psychological distress, and patient's
perceptions. Journal of Behavioral Medicine. 8, 61-78.


10
pain relief and at the end of five years, 90% of the surgery
patients failed to experience satisfactory pain relief. In
a study of conservative medical treatment, Finneson (1973)
reported findings that only 50% of the population studied
reported significant pain relief with conservative treatment
after three years. Thus, it was concluded that traditional
medical treatments did not exceed a 50% success rate and,
therefore, treatment successes could not be distinguished
from spontaneous remission rates.
Fordyce (1988) reported a prospective study of acute
low back pain patients in which he addressed differential
treatment recommendations as they effected long-term
outcome. Patients presenting to a hospital emergency room
with acute low back pain were randomly assigned to one of
two groups. The first group (Group A) received open ended
instructions such as to take medication as their pain
dictated, to exercise when their pain subsided or as
tolerated, and to remain in bed for an unspecified time. In
contrast, the second group (Group B) was instructed to take
medication at a fixed time interval and for a specified
duration, to remain in bed for only a specific period of
time, and to exercise according to a pre-set regimen. At
six weeks follow-up, there were no differences between the
groups, but at 9 to 12 months follow-up there were
significant differences found. Group A (open-ended
instructions) was found to report more physical impairments,


63
treatment change scores on the psychosocial dysfunction
scale. The treatment group decreased their scores and the
control group increased in their reported psychosocial
dysfunction (F(2,52)=5.05, p < 0.03). There were no
pre/post-treatment differences in recreational activities or
routine exercise regimens on the activities questionnaire.
(See Table III.)
The third hypothesis proposed that exercise and
increased low back strength would result in beneficial
reductions in psychological distress and pain. Analysis of
pre-treatment scores on perceived stress and measures of
anxiety and depression (defined as psychological distress on
the Mental Health Inventory) indicated that both groups
experienced severely high levels of perceived stress and
psychological distress pre-treatment and the control group
expressed significantly higher levels than the treatment
group. Analysis of covariance which used pre-treatment
scores as the covariate and change scores as the dependent
measure revealed no treatment differences between groups for
stress, anxiety and depression, or psychological well-being.
Although all subjects reported high levels of stress and
distress over the course of the study, there were no pre
treatment difference between groups on the level of self-
reported pain as measured by the pain subscale of the
WHYMPI. In contrast, utilizing pre-treatment pain scores as
the covariate in an analysis of covariance for changes in


45
between them was a measure of fatigue. Hence, the first
MedX assessment provided a baseline isometric strength
curve.
For the next two consecutive clinic visits, subjects
were instructed in the proper use of the MedX lumbar
extension machine under the supervision of one of three
registered physical therapists. MedX instruction and
training consisted of isotonic exercise at a work load of
1/2 the subject's peak isometric strength (torque in N.m).
When the subject exceeded 12 repetitions, the resistance was
increased 5 foot pounds. When subjects returned for their
fourth clinic visit, they were again administered the
isometric strength test which generated a second force
curve. In order to control for familiarity and variable
learning effects, this testing session was used as the pre
treatment strength measure. Subsequent training sessions
were performed twice per week for four weeks followed by
once per week for an additional six weeks. Strength curves
were then re-generated for assessment of changes in muscle
strength post-exercise.
Self-Report Questionnaires
All subjects completed a demographic questionnaire
which consisted of questions to assess race, sex, age,
marital status, occupation, work status, and litigation
status. Questions pertaining to the subject's pain history
included whether there was a precipitating event to their


80
treatment measures of activities, locus of control, pain,
and social support was limited to 28 percent of the variance
being explained by reported pain, the previous week's
activity level, and external and internal locus of control.
Of these measures, pain was the single most influential
variable and accounted for 19 percent of the variance.
Social support did not contribute to the predictive ability
of therapeutic gain. There was only one positive
correlation with strength changes and that was with internal
locus of control (self-efficacy). Measures of psychological
distress, pain, and physical and psychosocial impairments
were significantly correlated with decreased changes in
strength.
Implications
The findings of this study support the hypothesis that
strengthening the lumbar extensor muscles in a chronic pain
population is a beneficial treatment modality. The
literature reviewed suggested that increased physical
fitness and strength was an important treatment modality,
but the specific role of exercise in a chronic low back pain
syndrome population has not been clearly documented.
Although the subjects participating in the current study
were treated in an out-patient program, they do resemble
subjects found in multidimensional pain treatment programs
in terms of their chronicity of pain problem, psychological
distress, and socio-environmental disruption. Hence, the


97
Turk, D.C. and Kerns, R.D. (1984). Conceptual issues in the
assessment of clinical pain. International Journal of
Psychiatry in Medicine. 13, 57-68.
Turk, D. C., Meichenbaum, D., and Genest, M. (1983).
Cognitive Therapy of Pain. New York: Guilford Press.
Turk, D.C., Wack, J.T., and Kerns, R.D. (1985). An
empirical examination of the "pain-behavior" construct.
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Tursky, B., Jamner, L.D., and Friedman, R. (1982). The pain
perception profile: A psychophysical approach to the
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394.
Urban, B.J. (1982). Therapeutic aspects in chronic pain:
Modulation of nociception, alleviation of suffering, and
behavioral analysis. Behavior Therapy. 13, 430-437.
Veit, C.T. and Ware, J.E. (1983). The structure of
psychological distress and well-being in general
populations. Journal of Consulting and Clinical
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Waddell, G. (1987). A new clinical model for the treatment
of low back pain. Spine. 12, 632-644.
Weisenberg, M. (1977). Pain and pain control.
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312.
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90
Chapman, C.R., Casey, K.L., Dubner, R., Foley, K.M.,
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Non-organic chronic intractable pain: A comparative
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68
TABLE IV
MULTIPLE REGRESSION OF THE RELATIONSHIP OF PRE-TREATMENT
PSYCHOLOGICAL VARIABLES TO POST-TREATMENT INTERCEPT VALUES
Step Variable Model Partial F p Beta
R2 Statistic Value Weight
Pain
0.19
0.19
12.12
0.001
-12.3
Activity
0.24
0.05
3.05
0.08
12.7
External
LOC
0.28
0.04
2.52
0.12
3.5
Internal
LOC
0.28
0.01
0.69
0.41
1.3
4


TABLE OF CONTENTS
Page
ACKNOWLEDGEMENTS iii
LIST OF TABLES vi
ABSTRACT vii
CHAPTERS
1 INTRODUCTION 1
Chronic versus Acute Pain 2
Treatment of Chronic Pain 9
Self-Efficacy and Decreased Avoidance of
Physical Activities 20
Physical Reconditioning as a Way of
Improving Muscular Strength and
Psychological Symptoms 28
General Effects of Exercise on
Psychological Functioning 30
Exercise in Chronic Low Back Pain
Patients 33
Exercise of the Low Back 35
Hypotheses 40
2 METHOD 43
Subjects 43
Equipment and Measures 44
MedX Assessment and Training 44
Self-Report Questionnaires 45
Procedures 51
Experimental Group 52
Wait-List Control Group 52
Statistical Analysis 53
3 RESULTS 56
Physiological Results 58
Psychological Results 59
iv


65
reported pain, there was a significant difference found
between groups with the treatment group reporting a
significant reduction in pain and the control group
reporting an increase in pain (F(2,51)=6.83, p < 0.002).
It was originally hypothesized that social support,
self-efficacy, and pain reports would predict attrition or
adherence to the exercise program, and therapeutic gains.
Since attrition was limited (i.e., one drop-out), factors
associated with attrition could not be ascertained.
Analysis of the Social Support subscales of the WHYMPI
indicated pre-treatment differences in perceived support
with the treatment group reporting higher levels of positive
support and the control group higher levels of negative
support. In contrast, there were no post-treatment
differences in perceived negative or positive support which
may be reflective of a simple regression towards the mean.
In assessing the individual's perceived ability to master
the exercise program, there were no pre-treatment
differences between groups on internal or external locus of
control, but there were significant post-treatment
differences found. An analysis of covariance with pre/post
treatment change scores indicated that the treatment group
maintained a high internal locus of control whereas the
control group decreased on internal locus of control
(F(2,50)=6.07, p < 0.02) and changed to a perceived external
locus of control (F(2,50)=4.59, p < 0.04). (See Table III.)


27
emotional responses and subsequent opioid activation. It
was further concluded that self-efficacy is a causal
determinant of performance and is the moderating factor on
the subject's pain tolerance (Bandura et al., 1987; Litt,
1988; Taylor, 1989).
This line of research has also examined the role of
setting exercise quotas and subsequent self-efficacy ratings
in the clinical treatment of chronic pain patients. Two
articles were reviewed in which subjects were referred to a
pain-management clinic and assessment measures were taken
with respect to their actual ability to accomplish set
exercise quotas and their self-efficacy expectations. Self-
efficacy ratings were found to be predictive of actual
participation in physical exercise and in maintaining
physical activities post-treatment (Dolce, Crocker,
Moletteire & Doleys, 1986; Dolce, Crocker, & Doleys, 1986).
These studies suggest that chronic pain patients need
to be desensitized to their fear of activities, need to
develop a sense of mastery over their pain by actual
activity performance, need to develop the belief that the
demands of an aversive situation (exercise) are not greater
than their coping skills, and need to have an internal
attribution for treatment success. In addition, these
investigators found that the patient's past learning history
of successes and failures were often a primary determinant
of their self-efficacy ratings. In summary, self-efficacy


CHAPTER 3
RESULTS
There were no significant differences between groups on
demographic variables or pain histories pre-treatment.
There were also no differences between groups in their
medical examination (i.e., grimacing, ambulation, or
cooperativeness). Subjects were most frequently diagnosed
with combinations of low back pain with sciatica (56%), low
back pain without sciatica (43%) myofacial syndrome (50%),
spinal stenosis (28%), lumbar spondylosis (46%) and lumbar
instability (43%).
There were no significant differences between groups in
age, duration of their pain problem, medication usage, or
previous treatment histories. There was a significant
difference found between groups in the time since last
worked with the control group reporting more time since they
last worked compared to the treatment group (F(l,42)=4.10, p
< 0.05). When addressing medical treatments and activities
during the study, there were no differences found at the end
of the protocol between the control and treatment groups.
(See Table I.)
56


87
psychological distress in the wait-list group may have been
a result of the continued lack of beneficial treatment
interventions.
Conclusions and Future Directions
This study found that after 14 exercise sessions on the
MedX lumbar extension machine, a chronic low back pain
syndrome population significantly increased in measured
strength and decreased in reported pain. There were
significant changes found in physical and psychosocial
dysfunction post-treatment. Treatment gains were associated
with enhanced self-efficacy which has the potential for
positive impacts on future performance and disability.
Future research is needed to address the different
patient populations with chronic low back pain that would
benefit from exercise on the MedX lumbar extension
machine. Perhaps, patients with less physical and
psychosocial impairments would have experienced even greater
physical and psychological gains.
Given the chronicity of pain and deficits in physical
strength of this patient population, a treatment program
longer than 12 weeks may be necessary. A longer treatment
program may produce different results in terms of increases
in strength as well as increases in range of motion.
Additional research is needed to address the long-term
benefits of exercise on the MedX lumbar extension machine
in a chronic low back pain syndrome population. Future


106
What type of over-the-counter drugs do you take for pain
relief?
7. Current Treatment History:
Have you consulted any of the following specialists for
low back pain since you were initially evaluated?
Acupuncturist
Yes
(
)
NO
(
)
Not
sure
(
)
Chiropractor
Yes
(
)
No
(
)
Not
sure
(
)
Faith healer
Yes
(
)
No
(
)
Not
sure
(
)
Family physician
Yes
(
)
No
(
)
Not
sure
(
)
General surgeon
Yes
(
)
No
(
)
Not
sure
(
)
Hypnotist
Yes
(
)
No
(
)
Not
sure
(
)
Internist
Yes
(
)
No
(
)
Not
sure
(
)
Neurologist
Yes
(
)
No
(
)
Not
sure
(
)
Orthopedist
Yes
(
)
No
(
)
Not
sure
(
)
Osteopath
Yes
(
)
No
(
)
Not
sure
(
)
Physical therapist
Yes
(
)
No
(
)
Not
sure
(
)
Psychiatrist
Yes
(
)
No
(
)
Not
sure
(
)
Psychologist
Yes
(
)
No
(
)
Not
sure
(
)
Rheumatologist
Yes
(
)
No
(
)
Not
sure
(
)
Other specialist


59
utilizing the pre-treatment torque as a covariate, the
results were consistent with the increases in intercept and
indicated that the treatment group significantly increased
their strength at all angles within the subject's range of
motion. (See Table II.)
Psychological Results
The second hypothesis suggested that increased strength
in the low back muscles would be associated with increased
functional abilities. The physical and psychosocial
subscales of the Sickness Impact Profile were utilized to
address this hypothesis. Results of the pre-treatment
analysis indicated that the control group reported
significantly more physical and psychosocial dysfunction
when compared to the treatment group. Controlling for pre
treatment differences by utilizing the pre-treatment scores
as a covariate in an analysis of covariance, there were
significant differences between the groups in pre/post
treatment change scores on the physical dysfunction scale.
The treatment group reduced their scores in reported
physical dysfunction after exercise and the control group
increased in their reported physical limitations
(F(2,52)=4.77, p < 0.03). A similar trend was found on the
psychosocial subscale. Controlling for pre-treatment
differences by utilizing the pre-treatment scores as a
covariate in an analysis of covariance, there were
significant differences between the groups in pre/post-


2
low back pain patient focuses not only on spinal
abnormalities but also on the surrounding soft tissue areas.
Chronic versus Acute Pain
The experience of pain is described as acute or
chronic. Acute pain is often defined as a neural response
to a perceptual experience caused by a noxious stimulus.
This experience then leads to suffering and negative
affective states. These pain-eliciting states are
interpreted by the individual as signals of a problem that
reguires intervention (Bono & Zasa, 1988). Hence, the
experience of acute pain is believed to be correlated with a
physiological process and the associated pain subsides when
the symptoms are resolved.
Chronic pain is different from acute pain because the
symptoms are present and persistent for an extended period
of time. Chronic pain has been arbitrarily differentiated
from acute pain by establishing a time frame of
approximately six months. This time criteria was derived
from research by Sternbach (1974) which found personality
differences between patients who suffered pain for less than
six months compared to those who suffered for more than six
months. Patients who suffered longer durations of pain were
noted to have higher elevations on the clinical scales of
the Minnesota Multiphasic Personality Inventory (MMPI),
suggesting increasing psychological distress with increasing
durations of pain.


93
Holroyd, K.A., Penzien, D.B., Hursey, K.G., Tobin, D.L.,
Rogers, L., Holm, J.E., and Marcille, P.J. (1984).
Change mechanisms in EMG biofeedback training: Cognitive
changes underlying improvements in tension headache.
Journal of Consulting and Clinical Psychology. 52, 1039-
1053.
Hughes, J.R. (1984). Psychological effects of habitual
aerobic exercise: A critical review. Preventive
Medicine. 13. 66-78.
Hughes, J.R., Casal, D.C., and Leon, A.S. (1986).
Psychological effects of exercise: A randomized cross- over
trial. Journal of Psychosomatic Research. 30. 355- 360.
Jackson, C.P. and Brown, M.D. (1983). Is there a role for
exercise in the treatment of patients with low back pain?
Clinical Orthopaedics and Related Research. 179. 39-45.
Jones, A., Pollock, M., Graves, J., Fulton, M., Jones, W.,
MacMillan, M., Baldwin, D., and Cirulli, F. (1988).
Safe. Specific Testing and Rehabilitative Exercise for
the Muscles of The Lumbar Spine. Santa Barbara, CA.:
Sequoia Communications.
Kaye, G.V. (1985). An innovative treatment modality for
elderly residents of a nursing home. Clinical
Gerontologist. 3, 45-51.
Keefe, F.J. and Gil, K.M. (1986). Behavioral concepts in
the analysis of chronic pain syndromes. Journal of
Consulting and Clinical Psychology. 54. 776-783.
Keller, S. and Seraganian, P. (1984). Physical fitness
level and autonomic reactivity to psychosocial stress.
Journal of Psychosomatic Research. 28. 279-287.
Kerns, R.D., Turk, D.C., and Rudy, T.E. (1985). The West
Haven-Yale multidimensional pain inventory (WHYMPI).
Pain. 23, 345-356.
Kleinke, C.L. and Spangler, A.S. Jr. (1988). Psychometric
analysis of the audiovisual taxonomy for assessing pain
behavior in chronic back pain patients. Journal of
Behavior Medicine. 11. 83-94.
Kowal, D., Patton, J., and Vogel, J. (1978). Psychological
states and aerobic fitness of male and female recruits
before and after basic training. Aviation. Space and
Environmental Medicine. 49, 603-606.


53
pain rating prior to their second lumbar strength test.
After lumbar strength testing, this group was asked to wait
10 weeks before beginning treatment. They were requested
not to change their current exercise and activities or their
methods of treating their pain. At the end of 10 weeks,
these subjects again completed all self-report
questionnaires and were retested on the MedX lumbar
extension machine. They then followed the same treatment
protocol as the experimental group.
Statistical Analysis
The design of this study enabled the investigator to
measure changes on measures of psychological status,
functional abilities, and physical strength as a function of
treatment. Subjects were randomly assigned to a wait-list
control or treatment group. Pre- and post-treatment
differences on demographic variables and medical treatment
histories were addressed with multivariate analysis of
variance and Chi-square statistics.
Analysis of physical strength
Due to the chronicity and physical limitations of this
population, most subjects were unable to complete a full
range of motion within a standard arch of 72 degrees. In
order to standardize the data for group comparisons,
regression equations (Torque=angle(x) + intercept) for pre-
and post-treatment MedX testing sessions were computed for
each subject based on their actual performance within their


84
In this study, treatment success was defined by
increased strength and decreased pain, and not by return to
work. This study attempted to focus on the specific effects
of exercise in the rehabilitation of chronic pain patients.
Studies addressing treatment outcome with return to work are
heavily weighted with socio-environmental influences and it
is therefore difficult to evaluate the beneficial treatment
components. In summary, exercise of the low back in a
chronic low back pain syndrome population is a necessary
treatment component, but it does not in and of itself,
ameliorate psychological distress or socio-environmental
influences. This implies that physical rehabilitation,
psychological rehabilitation, and return to work are
distinct areas of the treatment process and need to be
evaluated independently.
Limitations of the Study
This study examined the relationship between
psychological distress and exercise of the low back muscles
after twelve weeks of treatment in a chronic low back pain
syndrome population. Although subjects were randomized at
the beginning of treatment, the control group was found to
exhibit higher levels of psychological distress and
dysfunction pre-treatment. The finding of increased
psychological distress and pain in the control group as
compared to the treatment group may have been influenced by
these pre-treatment differences.


57
TABLE I
SUBJECT CHARACTERISTICS OF THE WAIT-LIST CONTROL
AND TREATMENT GROUPS STUDIED FOR EFFECTS OF
EXERCISE OF THE LOW BACK MUSCLES
Treatment
Control
Group
Group
N=31
N=2 3
Sex
Male
18
16
Female
13
7
Unemployed due to
Back Pain
42%
52%
Diagnosis
Low back pain with
sciatica
18
12
Low back pain
without sciatica
12
11
Myofacial Syndrome
13
14
Spinal Stenosis
7
8
Lumbar Spondylosis
15
10
Lumbar Instability
13
10
Average age
44 (22-70
yrs.)
47 (25-70 yrs.)
Average duration
of Pain in months
84 (12-312
: mos.)
89 (12-288 mos.)
Time since
last worked
in months
22 (0-132
mos.)
56 (1-168 mos.)*
Daily Hours in
Pain
Pre-treatment
13 (2-24 hrs.)
15 (2-24 hrs.)
* E < 0.05


55
self-reported pain, and psychological variables of distress,
dysfunction, and social support to address the magnitude of
the relationship between psychological measures and changes
in strength.


18
and are not candidates for surgical interventions.
Treatment success is high in these studies, but it should be
noted that insurance companies pay for these programs and
they expect their clients to return to work or receive final
disability at completion. Hence, it is not surprising that
subjective measures of experienced pain are not considered
predictive of a successful outcome, but instead, return to
work is the measure of successful outcome. Additionally,
there is a selection bias inherent in these studies due to
the fact that some insurance companies refuse to pay and
some subjects refuse to participate due to the knowledge of
a potential risk to their economic situations (Gatchel et
al., 1986; Mayer, Gatchel, Mayer, Kishino, Keeley, & Mooney,
1987; Mayer et al., 1986; Mayer, Smith, Keeley, & Mooney,
1985; Mayer, Gatchel, Kishino, Keeley, Capra, Mayer,
Barnett, & Mooney, 1985).
Given that chronic pain patients suffer differentially
with physiological symptoms, psychological distress, and
environmental disruption, it is important to understand the
components of multimodal treatment programs that are
beneficial. Since treatment success is often defined as
increased functional activity (Gottlieb et al., 1977), it is
reasonable to assume that the effective ingredient might be
the physical reconditioning component. On the other hand,
improved psychological well-being may lead to improved
functioning and increased activity (Weisenberg, 1987).


82
limitations. This finding suggests that life-style changes
in daily activities may not be related to perceived changes
in limitations. Hence, exercise alone does not impact on
activities of daily living and instead, socio-environmental
factors may be more determinant and should be addressed
separately.
Exercise alone did not influence measures of
psychological distress. This finding is consistent with the
literature reviewed in that these subjects reported severe
levels of psychological distress. It may be that as the
chronicity of pain and disability increase, that
psychological distress is more closely associated with
socio-environmental influences (e.g., workmen's
compensations, unemployment, availability of work, financial
stability, and adaptation to a sick role) than to physical
limitations and pain. The implications from these findings
are that patients exhibiting a chronic low back pain
syndrome improve in physical strength, and they experience a
reduction in pain following physical exercise. The
perceived or actual limitations for returning to gainful
function in society remains impaired and potentially
exacerbates psychological distress. Hence, the failure to
find improvement in psychological distress in this study
suggests that multidisciplinary treatment programs that
emphasize physical reconditioning need to address vocational


79
hot/cold packs and massage) fail to ameliorate the symptoms,
the subject's self-efficacy expectations decline and in
turn, they seek external resources for meeting their needs.
On the other hand, subjects that experienced success with
exercise and subseguent reductions in pain were more apt to
internalize their treatment goals and maintain strong self-
efficacy expectations.
It was originally hypothesized that social support
would predict attrition and therapeutic gains. Attrition
was not addressed in this study due to a high adherence
rate. Neither negative nor positive social support as
measured on the WHYMPI were predictive of changes in
strength at the end of treatment. Although the majority of
this sample were married, a supportive relationship was not
related to therapeutic changes in strength or pain. The
exercise literature suggests that social support is an
important factor in maintaining exercise objectives over
time. In contrast in the chronic pain patient, the role of
pain may be the predominant factor associated with
therapeutic endeavors which supersedes the role of social
support.
In conclusion, changes in strength were positively
associated with decreased pain reports and increased
physical and psychosocial functioning. There was no
relationship between changes in strength and psychological
distress. Additionally, the predictive ability of pre-


6
1965), to the influence of social modeling (Craig, Best, &
Ward, 1975), to the mood states of the patient (Clark, 1974;
Turk & Kerns, 1984), to previous learning and medical
management (Fordyce, 1988), and to a physiological
hyperactivity (Flor & Turk, 1989).
For example, Sternbach and Tursky (1965) interviewed 60
subjects from four different ethnic backgrounds and obtained
information regarding the subject's past reactions and
perceptions to pain. Subjects then participated in a
laboratory experiment which tested pain thresholds,
estimated stimulus intensities, and autonomic reactivity.
Findings of this study indicated that different subcultural
groups hold different attitudes (e.g., "pain is to be
suffered in silence" versus "fear the worst") about pain and
that based on these attitudes, they experience pain
differentially.
Another experimental study by Craig et al. (1975)
exposed 30 undergraduate students to various levels of
shock. This study found that subjects differed in their
reported experience of pain as a function of being exposed
to a pain-tolerant model versus a pain-intolerant model.
Subjects exposed to a pain-intolerant model reported more
pain. Hence, this study lends support not only for the
cognitive-mediation in the experience of pain, but also in
the influential role of social-environmental mediators.


17
specific physical or psychological effects of a
comprehensive treatment program. Philips (1987) reported a
cognitive-behavioral treatment program that utilized random
assignment to a wait-list control or treatment group. He
found that 83% of the subjects in the treatment group
improved relative to the control group. Treatment consisted
of teaching the patients techniques to manage and control
their pain and techniques to increase their exercise levels
and physical fitness. Hence, improvement was described as
increased physical fitness levels and decreased
psychological distress (Philips, 1987).
In a study by Heinrich, Cohen, Naliboff, Collins and
Bonebakker (1985), chronic pain patients were assigned to a
physical therapy treatment or to a behavior therapy program.
Both treatments addressed increasing activity levels. They
found that both groups improved after treatment, and
interestingly, there were no significant differences between
the two groups at 6- and 12-month follow-ups.
Studies addressing physical reconditioning and
cognitive behavioral treatments in multimodal treatment
programs report significant improvements after treatment and
at long-term follow-up. Improvements typically are defined
as return to work or in training programs, decreased
psychological dysfunction, and increased physical
functioning. Subjects participating in these studies are
considered to be refractory to previous medical treatments


74
the control group. Since an increase in intercept is
indicative of an increase in, torque generated, it was
concluded that isotonic exercise on the MedX lumbar
extension machine resulted in increased muscle strength
post-treatment.
An additional analysis comparing change scores at each
standard angle supported the results of the changes in the
intercepts. Standard angles were calculated for each
subject based on their actual range of motion when their
testing positions were found to vary a few degrees.
Comparisons were then performed utilizing pre-treatment
standard angles as the covariate in an analysis of
covariance with changes in torque as the dependent variable.
This analysis supported the previous analysis and indicated
that training on the MedX lumbar extension machine
increased lumbar strength by 11 to 17 percent whereas the
control group remained the same.
Psychological Findings
One of the most pronounced findings in this study was
that psychological factors found to be associated with
treatment outcome consistently improved in the treatment
group and worsened in the control group. Specifically,
treatment on the MedX lumbar extension machine resulted in
significant improvements in reported physical and
psychosocial dysfunction as measured by the Sickness Impact
Profile. Over the course of the 12 week protocol, the


32
esteem is very low (Hughes, 1984). Similarly, studies
looking at depression and anxiety find that mild to moderate
distress (as opposed to severe distress) can be modified by
exercise (Sinyor, Schwartz, Peronnet et al., 1983).
Dishman, Sallis, and Orenstein (1985) in their review
of the exercise literature found that as the severity of
psychological distress increased, there was a related
increase in withdrawal from exercise programs. These
authors conclude that continued participation in exercise
programs of all types was related to the individual's past
exercise history, perceived health, education, self-
motivation, and positive support from a spouse or
significant other. These conclusions are tentative at best
in that the literature they reviewed included diverse
populations and settings, various research traditions and
disciplines, and a variety of differing interpretations.
Although professionals and laymen alike, promote the
concept of "healthy body, healthy mind" (Sachs, 1982), most
of the research addressing this area is by anecdotal report,
or quasi-experimental designs. There are only a few studies
experimentally done which have investigated the
psychological benefits of exercise, and these have resulted
in conflicting results. These inconsistencies are
attributable to the lack of experimental designs, and to the
fact that many of the subjects had low levels of
psychological distress prior to treatment. In contrast, the


24
conditions consisted of increased versus decreased EMG
activity feedback, and high versus moderate successful
control feedback. Findings of this study were that changes
in post-treatment headache activity were induced by
performance feedback and were not related to actual EMG
activity. In summary, whether the subjects were told that
they successfully increased or decreased EMG activity was
not significant in their subsequent reduction of headache
pain. Instead, the high success feedback significantly
decreased headache pain post-treatment regardless of the
direction of EMG activity. Hence, these authors proposed
that high success feedback increased the subject's self-
efficacy expectations which subsequently reduced their
headache pain.
Self-efficacy expectancies were evaluated in a study of
chronic pain patients involved in a nine week outpatient
treatment program (Philips, 1987). This treatment program
was done in a small group format and focused on teaching the
patients new coping strategies and on increasing their
activity levels. Self-efficacy ratings were taken for 40
consecutive subjects who presented for treatment of chronic
pain. Twenty five subjects were assigned to treatment
groups and 15 subjects were assigned to a wait-list control
group. Subjects completed questionnaires on their number of
avoidance behaviors and on their perception of the severity
of their pain problem. There were no differences between


I certify that I have read this study and that in my
opinion it conforms to acceptable standards of scholarly
presentation and is fully adequate, in scope and quality, as
a dissertation for the deqree of Doctor of Philosophy.
Nancy K.Ckorvell, Chair
Assistant Professor of
Clinical and Health Psycholoqy
I certify that I have read this study and that in my
opinion it conforms to acceptable standards of scholarly
presentation and is fully adequate, in scope and quality, as
a dissertation for the degree of Doctor of Philosophy.
Assistant Professor of
Clinical and Health Psychology
I certify that I have read this study and that in my
opinion it conforms to acceptable standards of scholarly
presentation and is fully adequate, in scope and quality, as
a dissertation for the degree of Doctor of Philosophy.
Johnson
sssor of
cal and Hea
Psychology


26
rewards and reinforcement and that self-efficacy
expectations were significantly related to actual abilities
to tolerate pain (Dolce, Doleys, Raczynski, Lossie, Poole, &
Smith, 1986).
Another set of laboratory studies utilizing the cold
pressor test for pain stimuli reached similar conclusions.
Self-efficacy expectations in these studies were addressed
in conjunction with the role of cognitive mediation and
endogenous opioid involvement following pain stimulation.
Evidence of endogenous opioid mechanisms was found in
response to pain stimuli in addition to nonopioid cognitive
mechanisms. In these studies, a placebo medication group
increased their pain tolerance due to endogenous opioid
involvement, but did not increase their self-efficacy
ratings. In contrast, the cognitive strategy group
increased both their self-efficacy and pain tolerance.
Conclusions for the chronic pain patient based on these
laboratory findings were that strong self-efficacy may lead
to increased activities despite pain which potentially
exacerbates the pain and results in a cognitive loss of
control over the painful experience. Stress associated with
a sense of failing control with increasing pain then
activates endogenous opioid mechanisms for additional pain
control. Hence, it was noted that cognitive appraisals did
not effect the experience of pain, but instead increased the
subject's ability to endure pain which resulted in increased


78
was only one drop out in this study; therefore adherence was
not examined. Self-efficacy was measured with the Exercise
Locus of Control Scale. This measure assessed the subjects
perceived ability to master the exercise program in terms of
internal and external locus of control. Interestingly,
there were no pre-treatment differences between groups in
locus of control with both groups reporting a higher score
on internal locus of control. At post-treatment, the
control group's mean scores changed from a higher internal
locus of control to a higher external locus of control. In
contrast, the treatment group maintained their orientation
for an internal locus of control. These findings are
consistent with self-efficacy theory and indicate that
mastery of a given behavior will influence self-efficacy
expectations which will subsequently influence behavioral
performance.
In this study, internal locus of control (increased
self-efficacy) was the only psychological measure positively
correlated with changes in strength. Pre-treatment scores
of internal locus of control (self-efficacy) were not found
to be predictive of therapeutic gain as originally
hypothesized, but increased strength (treatment success) was
highly associated with maintenance of high self-efficacy
ratings. The change of focus from an internal to an
external locus of control in the control group suggests that
as pain persists and passive treatment modalities (i.e.,


36
lower extremities may also lead to improvement in other
areas of functioning. For example, Fredrickson, Trief,
VanBeveren, Yuan and Baum (1987) followed 80 chronic pain
patients referred to a multimodal six week outpatient
treatment program. They found that increased functional
strength after treatment was the best predictor of
successful outcome which was defined as decreased pain
experienced, increased activity levels, and/or return to
work.
Increasing the strength and elasticity of the lumbar
extension muscles should decrease chronic low back pain.
This is consistent with Keefe and Gil's (1986) pain-spasm-
pain model of the chronic pain patient. These authors state
that an initial painful event leads to a reflexive muscle
spasm, vasoconstriction, and the release of pain producing
substances. With time, this minimizes the pain and
additional spasm through reduced movement. This limited
movement, in turn, leads to muscle shortening and the
inactive muscles atrophy. The shortened, atrophied muscles
then predisposes the patient to more spasm and increased
pain. Therefore, increasing the physical fitness of the
lumbar muscles should decrease pain in patients with chronic
low back pain.
Jones, Pollock, Graves et al. (1988) propose three
primary reasons for myofacial low back pain: specific
muscular responses, type of muscle fiber, and chronic disuse


107
7. Since your initial evaluation, have you received any of
the following treatments for low back pain?
Nerve blocks
Yes ( ) No ( )
Biofeedback
Yes ( ) No ( )
Relaxation Techniques
Yes ( ) No ( )
Psychotherapy
Yes ( ) No ( )
Electrical nerve stimulation
Yes ( ) No ( )
Acupuncture
Yes ( ) No ( )
Chiropractic manipulation
Yes ( ) No ( )
Hypnosis
Yes ( ) No ( )
Exercise
Yes ( ) No ( )
Traction
Yes ( ) No ( )
Back brace
Yes ( ) No ( )
Pain treatment center
Yes ( ) No ( )
Whirlpool
Yes ( ) No ( )
Ultrasound
Yes ( ) No ( )
Massage
Yes ( ) No ( )
Vitamin or nutritional therapy
Yes ( ) No ( )
Body cast
Yes ( ) No ( )
Other
Yes ( ) No ( )
Specify:


47
and 0.57 for chance. Test-retest (three to four months)
were high for the powerful other and chance subscales (0.72
and 0.60, respectively), but were somewhat lower for the
internal scale (0.32). This test was originally developed
as a measure of predicting attrition, but it subsequently
was not found to be solely predictive of attrition. It was
found to be predictive of adherence to an exercise program
based on the individual's self-efficacy expectations and if
the individual's participation was perceived as a stress and
tension reducing mechanisms, in contrast to a perceived
social event.
Activity Recall Questionnaire
This measure was originally developed by Blair,
Haskell, Ping Ho et al. in 1985 to assess changes in an
individual's habitual exercise patterns. It provides a
general measure of the subjects' routine activities (e.g.,
climbing stairs, walking, and household chores) in addition
to their participation over a one week period in
recreational activities. It has been used in a large
epidemiology study which examined exercise habits in over
2,000 subjects (Blair, Haskell, Ping Ho et al., 1985). This
activity measure was found to significantly correlate with
dietary energy intake in a study of 495 males and 545
females. It has also been shown to be positively and
significantly correlated with physiological changes in
maximum oxygen uptake and body fat after exercise (Sallis,


3
Chronic pain patients have been described as being
poorly psychologically adjusted. As the chronicity of pain
exceeds six months, these individuals evidence behavioral
changes (i.e., restricted activities), emotional distress
(i.e., anxiety or depression), heavy medication usage, and
increased reliance on the health care system. These factors
as well as many others are often explained in the literature
as a result of increased psychological distress created by
the patients' long-term disabilities in relation to their
psychosocial and economical environments (Bono & Zasa, 1988;
Urban, 1982). For example, Ackerman and Stevens (1989)
studied 110 patients presenting for treatment of acute and
chronic pain. These authors found that both groups
experienced increased levels of state anxiety, but the
chronic pain group was significantly differentiated from the
acute pain group in their experience of a negative affective
state (e.g., depression) which was again believed to be
associated with the chronicity of pain.
Bono and Zasa (1988) further differentiated the chronic
pain experience according to the individual's adjustment and
reaction to his/her pain. These authors reported that not
all chronic pain patients fail to adapt to their
difficulties and some continue to function well in society.
They identified patients with "chronic pain" as those who
are without deleterious psychosocial/environmental


48
Haskell, Wood et al., 1985). Since it was suggested that
past exercise experience may predict outcome, this measure
was used to predict compliance and completion of the
treatment program.
West Haven-Yale Multidimensional Pain Inventory
Subjects completed the West Haven-Yale Multidimensional
Pain Inventory (WHYMPI; Kerns, Turk, & Rudy, 1985). This is
a 52-item self-report questionnaire that is consistent with
a cognitive-behavioral conceptualization of the chronic pain
syndrome. Studies using this brief measure report that it
is psychometrically sound and when used in treatment outcome
studies it has been found to be a reliable and valid
assessment instrument for chronic pain patients (internal
consistency ranging from 0.70 to 0.90, and stability
coefficients ranging from 0.62 to 0.91).
There are three parts of this inventory that examine the
impact of pain on the subject's lives by addressing their
perception of positive and negative social support, their
activity levels, and their current levels of experienced
pain and depression. The positive/negative social support
subscales were used to predict attrition and therapeutic
gains. A subject's perception of their pain intensity was
also measured with this questionnaire by having them rate
their current pain and their pain for the last week.


54
varying range of motions. This enabled the investigator to
obtain the slope and intercept of the regression line
resulting from the generated force curve for each subject.
The pre-treatment slopes and intercepts were used as a
covariate in an analysis of variance for between group
differences post-treatment. Change scores between pre- and
post-treatment were used as the dependent variable.
Additionally, the estimated torque values based on the
regression analysis at standardized angles (angles of 0, 12,
24, 36, 48, 60, and 72 degrees) within the subject's range
of motion were compared post-treatment utilizing the pre
treatment standard values as the covariate in an analysis of
covariance.
Analysis of psychological measures
Psychological measures for between group comparisons
were analyzed using pre-treatment scores as the covariate in
a multivariate analysis of covariance for between group
differences. Change scores were used as the dependent
variable. Secondly, locus of control (internal and
external), activities, positive social support, and the pain
rating scale were entered into a step-wise multiple
regression analysis for prediction of outcome as assessed by
their relationship with the post-treatment intercept.
Finally, Pearson Correlation Coefficients were computed
between the variables of post-treatment strength (as
measured by the changes in intercept scores post-treatment),


33
chronic low back pain patient is a unique population which
appears to experience significant psychological turmoil
(Gottlieb et al., 1977). Hence, the role of exercise may
have a more pronounced effect in this population. This
suggestion is consistent with the finding that treatment
programs that focus on increasing activity levels (well-
behavior) and decreasing sick behaviors (inactivity) have
been shown to be an effective treatment for chronic low back
pain patients (Block, 1982).
In summary, if exercise and physical reconditioning
does enhance an individual's ability to cope with stress,
and decreases anxiety and depressive symptomatology,
increasing the chronic low back pain patient's physical
activity through a structured exercise program should result
in his/her experiencing an improved psychological well-being
and decreased pain.
Exercise in Chronic Low Back Pain Patients
Studies addressing exercise in chronic low back pain
have found that exercise is beneficial in reducing pain and
increasing physical functioning (Bigos & Battie, 1987).
Exercise is reported as a major focus of treatment in 100%
of pain treatment clinics and in 86.8% of all patients with
reports of pain (Tollison, Kriegel, & Satterthwait, 1989),
but the beneficial role of exercise is not understood in the
treatment of chronic low back pain. For example, Jackson
and Brown (1983) state that the reasons for recommending


11
disrupted vocational status, increased levels of health care
utilization, and higher levels of pain. The conclusions
drawn from this study were that subjects with vague open-
ended guidelines for treatment experienced increased pain
from muscular disuse and then potentially interpreted their
pain as a failed healing process. These findings are of
particular import in that they document the role of
expectancy in the efficacious treatment of acute pain and
its relationship to the later development of chronic pain.
This is consistent with Waddell's (1987) contention that
physical illness, illness behavior and psychological
distress combine to produce disability. Bigos and Battie
(1987) reached a similar conclusion stating that there is an
important difference between treating back pain and
preventing chronic back pain disability. Hence, the
interaction between physical illness, pain behaviors and
psychological states may determine the outcome of treatment
of acute pain, while continued disability, work loss, and
failure to return to work may be more related to social
factors than physical disease (Waddell, 1987).
In order to better address and treat the chronic pain
phenomenon, many treatment interventions focus on
psychological variables associated with chronic pain. In
addition to the subjective experience of pain, chronic pain
patients frequently report psychological distress, including
symptoms of anxiety and depression. Thus, as Gottlieb et


TABLE III
PSYCHOLOGICAL DYSFUNCTION AND PAIN
PRE/POST-TREATMENT MEANS AND STANDARD DEVIATIONS
64
Treatment Group Control Group
Pre/posttreatment Pre/posttreatment
(SD) (SD)p Value
Sickness Impact
Profile:
Physical
9.1
7.7
15.2
19.3
Dysfunction
(9.3)
(9.4)
(10.4)
(15.6)
£<0.03
Psychosocial
12.5
10.3
20.8
24.8
Dysfunction
(14.3)
(12.8)
(18.0)
(23.7)
P<0.03
Mental Health
Inventory:
Psychological
58.8
59.0
71.7
70.3
Distress
(18.8)
(20.9)
(28.9)
(32.5)
ns
Psychological
51.3
52.2
45.1
46.8
Well-Being
(13.9)
(14.5)
(18.1)
(19.0)
ns
West Haven-Yale
Multidimensional
Pain Inventory:
Pain Subscale
3.4
2.9
3.7
4.1
(1.6)
(1.7)
(1.6)
(1.5)
P<0.002
Positive Support
3.6
3.4
2.6
3.0
Subscale
(1.3)
(1.5)
(1.7)
(1.5)
ns
Negative Support
1.2
1.2
2.1
1.7
Subscale
(1.0)
(1.1)
(1.5)
(1.4)
ns
Exercise Locus
of Control:
Internal
23.3
23.9
21.8
19.9
Control
(5.2)
(4.4)
(5.2)
(6.7)
P<0.02
Other
12.0
11.7
11.6
13.1
Control
(3.7)
(3.7)
(3.8)
(3.8)
E<0.04


7
Several studies have found that psychological variables
are frequently associated with reports of pain, especially
depression and anxiety. Not only do clinically depressed
patients frequently report pain symptoms, but pain patients
frequently report depressive symptoms (Weisenberg, 1977).
For example, a study comparing 33 chronic low back pain
patients to 35 healthy controls found that depression and
anxiety were commonly reported in the low back pain group,
not in the control group. It was further noted that the
severity of depression and anxiety were positively
correlated with increased pain reports (Feuerstein, Suit, &
Houle, 1985). The role of anxiety in pain is further noted
in Weisenberg's (1977) statement that patients who trust
their physicians reduce their presenting anxiety and this
leads to decreased pain reports and increased responsiveness
to placebo treatments. For example, laboratory studies
utilizing psychological procedures such as attention
diversion, cognitive restructuring, and hypnotic inductions
have been found to significantly reduce anxiety and
subsequently the experience of pain (Bandura et al., 1987;
Spanos, Perlini, & Robertson, 1989), Additionally,
psychological measures of depression and anxiety decrease
significantly with decreased pain after treatment (Gatchel,
Mayer, Capra, Diamond, & Barnett, 1986).
There are other theories and models attempting to
explain the experience of chronic pain. For example,


35
medical visits, and had fewer relapses. Additionally, the
significant factors found to relate to decreased pain were
the number of exercise sessions completed, decreased body
fat, and increased aerobic fitness.
In summary, the studies reviewed on the relationship
between exercise and psychological functioning are
inconclusive. Despite these discrepant findings, there does
appear to be some psychological benefits associated with
exercise. The role of exercise in treating chronic low back
pain also appears to be a beneficial treatment modality, but
the role of exercise in the chronic pain syndrome needs
further investigation. Given the suggestion that trunk
extension strength is the most severely affected area in low
back pain patients, exercise and rehabilitation of this area
is a viable treatment modality open for investigation
(Smidt, Herring, Amundsen, Rogers, Russell, & Lehmann,
1983).
Exercise of the Low Back
Recent investigators who have suggested that physical
reconditioning can be beneficial for the low back pain
patient emphasize that exercise regimens should recondition
the specific atrophied muscles (Feuerstein et al., 1987;
Mayer et al., 1985). Chronic disuse of specific spinal
muscles can exacerbate existing low back pain (Rosomoff,
1985). In addition to preventing exacerbation of the pain
experience, strengthening the muscles of the low back and


88
research is currently under way to investigate the long-term
effects of exercise on the MedX lumbar extension machine
on psychological distress, return to work, and changes in
daily activities.
In conclusion, this study demonstrated that exercise on
the MedX lumbar extension machine significantly
strengthened the low back extensor muscles in a population
of chronic low back pain syndrome patients. Associated
improvements were also found in the experience of pain and
physical and psychosocial dysfunction. Given that strength
changes with specific exercises of the extensor muscles have
been shown to increase strength in both healthy and low back
pain subjects, future research is needed to address the
potential benefits of this exercise modality on prevention
of future back injuries and the chronic low back pain
syndrome.


TORQUE
250
ANGLE
PRE-TREAT
PRE-CONTROL
POST-TREAT
POST-CONTROL
FIGURE I
PRE-POST TREATMENT TORQUE
(REGRESSED MEANS RANGING FROM 0 TO 72 DEGREES)


14
Psychological interventions usually include cognitive-
behavioral techniques. For example, Fordyce (1976) proposes
that pain behaviors are maintained by contingent events and
thus are amenable to behavioral interventions such as
undesirable consequences for certain pain behaviors.
Similarly, within this behavioral framework, increases in
activity levels are encouraged and rewarded. Since social
factors have been found to have a significant impact on the
chronic pain experience, many psychological interventions
include family therapy to address the role of positive and
negative social reinforcement from significant others.
Patients are often instructed in relaxation and biofeedback
techniques, and various coping strategies are taught (such
as pacing daily activities). In terms of more cognitive
interventions, faulty cognitions are challenged. This
teaches the patient to identify and relabel negative and
defeating self-statements, which leads to more adaptive
functioning. Psychological interventions are also
accomplished with individual psychotherapy or group therapy
sessions. These psychological interventions focus on faulty
cognitions, affective reactions, and ineffective coping
strategies, while at the same time they encouraged the
patient to increase his/her physical activities. Hence, the
psychological component of these programs is heavily laden
with a physical componentincreased activity (Block, 1982).


CHAPTER 4
DISCUSSION
This study examined the effects of exercise on the
MedX lumbar extension machine in a chronic low back pain
syndrome population. It was hypothesized that after a 12
week exercise program subjects would improve in lumbar
extensor strength and that improvements in strength would be
associated with decreased physical and psychological
dysfunction.
The findings of this study confirmed that exercise on
the Medx lumbar extension machine substantially increased
low back strength in a sample of chronic low back pain
patients. These findings are of particular importance given
the chronicity and disability reported by this sample.
Additionally, increased strength was related to improved
physical and psychosocial functioning as measured by the
Sickness Impact Profile. On this measure, the treatment
group decreased in their report of dysfunction while the
control group increased on measures of physical and
psychosocial impairment. Interestingly, despite reporting
improved physical and psychosocial functioning, there were
no differences or changes in daily activity levels.
Exercise on the MedX lumbar extension machine was also
related to significant changes in self-reported pain.
70


41
The current study examined the specific benefits of
exercise performed on the MedX lumbar extension machine
with a diverse chronic low back pain population. It was
hypothesized that subjects completing MedX training would
show significant improvement in low back muscle strength as
compared to the control group. It was further hypothesized
that this strengthening program would lead to significant
improvement in post-treatment physical and psychosocial
dysfunction as assessed by subscales of the Sickness Impact
Profile. Physical reconditioning on the MedX lumbar
extension machine was also hypothesized to result in
decreased pain reports and psychological distress
(specifically anxiety and depression). These hypotheses
were based on previous research which suggested that
exercise can decrease anxiety and depression. Reductions in
self-reported pain were believed to be important given that
it is verbal complaints that result in patient referrals for
continued treatment (Kleinke & Spangler, 1988). Finally, it
was hypothesized that adherence to the training program on
the MedX lumbar extension machine and maintenance of
therapeutic gains would be predicted by the subject's self-
efficacy expectations, and social support (measured by the
Exercise Locus of Control Scale and the Social Support
subscale of the West Haven-Yale Multidimensional Pain
Inventory, respectively). This hypothesis is consistent
with the finding that self-efficacy expectations influence


Abstract of Dissertation Presented to the Graduate School
of the University of Florida in Partial Fulfillment of the
Requirements for the Degree of Doctor of Philosophy
LUMBAR STRENGTHENING IN CHRONIC LOW BACK PAIN PATIENTS
PSYCHOLOGICAL AND PHYSIOLOGICAL BENEFITS
By
Sherry V. Risch
May 1990
Chairman: Nancy K. Norvell, Ph.D.
Major Department: Clinical and Health Psychology
This study examined the effects of dynamic exercise on
the isometric strength of the lumbar extensors in a chronic
low back pain population. It was hypothesized that exercise
on the MedX machine would result in increased lumbar
strength which would be associated with decreases in pain
and physical and psychosocial impairments.
Fifty-five chronic low back pain subjects participated
in the study. Thirty-one patients were randomly assigned to
a treatment group and 23 patients were assigned to a wait
list control group. Prior to participating in the study,
all subjects were tested on the MedX machine for isometric
strength and were administered psychological questionnaires
addressing physical and psychosocial dysfunction, pain,
stress, depression, and anxiety.
Treatment consisted of variable resistance dynamic
exercises two times each week for six weeks, followed by one
session each week for six weeks. The control group was
requested to make no changes in their current life-style or
vii


50
stressful in itself, but it is the perception of the
individual that an event is stressful that results in a
concomitant stress response. This measure has moderate
test-retest reliability (0.85 after two days, and 0.55 after
six weeks) and validity coefficients are reported from 0.52
to 0.76. In addition, this measure is reported to be a good
predictor of health related outcomes as assessed with PSS
scores and subsequent seeking of medical services (Cohen,
Kamarck, & Mermelstein, 1983).
Sickness Impact Profile
The Sickness Impact Profile (SIP, Bergner, Bobbitt,
Pollard, Martin & Gilson, 1976) is a 136-item test which was
selected to assess changes in functional abilities. The
measure provides scores for the impact of an illness in
three general dimensions; physical disability, psychosocial
dysfunction, and other dysfunction (work and recreation).
For purposes of this study, the physical and psychosocial
dysfunction dimensions were utilized. Original validation
was performed on a diverse medical population and it was
found to be significantly correlated with the patient's
self-report of physical disability, physician ratings of
their disability, and with daily activity diaries (0.29 to
0.52, Pearson correlation coefficients).
More recently, this measure was used to assess
functional status changes in chronic low back pain patients
following treatment interventions (Follick, Smith, & Ahern,


58
Physiological Results
It was hypothesized that exercise on the MedX lumbar
extension machine would strengthen the low back extensor
muscles. T-Test results indicated that there were no pre
treatment differences between groups in measures of
isometric strength as defined by the pre-treatment intercept
scores and slopes of the regression line. At post-treatment
utilizing an analysis of covariance with pre-treatment
scores as a covariate and the change scores as the dependent
variable, there were no differences between groups in the
slope of the isometric strength curve, but there were
significant differences between the intercepts,
(F(2,52)=6.50, p < 0.01). Results indicated that the mean
intercept significantly increased in the treatment group
while it remained the same for the control group. Given the
drastic decline in the number of subjects at the 72 degree
angle, the slope of the regression line has been graphically
portrayed twice. Figure I represents the regression line
with a full range of motion with only 24% of the subjects
completing the 72 degree angle, and Figure II represents the
regression line up to 60 degrees which encompasses 65% of
the sample. (See Figures I and II.). These findings
suggest that while the linear increase in strength was
consistent across the subject's range of motion between the
two groups, the treatment group generated consistently more
force post-treatment. When addressing each standard angle


67
related to increased strength, but with higher levels of
internal locus of control (r=-0.53, e<0.0001) and with
increased psychological well-being as measured by the MHI
(r=-0.56, £<0.0001). Pre/post-treatment changes in self-
reported pain were not significantly correlated with any of
the above variables. (See Table V.)
67


20
al., 1985). In summary, the impact of improved physical
conditioning on functional abilities as well as
psychological status has not been sufficiently examined in
chronic low back pain patients.
Self-Efficacy and Decreased Avoidance of Physical Activities
Dolce (1987) postulated that the chronic pain patient's
desire to avoid pain results in more severe limitations in
activity than do actual physical limitations. This
avoidance of physical activity is similar to the behaviors
seen in phobic patients. A chronic pain patient fears
certain activities because an earlier activity was
experienced as aversive which created pain, tension and
anxiety. Hence, the patient continues to avoid activities
perceived as similar to the initial anxiety/pain-inducing
situation. The avoidance behavior is then reinforced by the
fact that the patient avoids the experience of increased
pain (Philips, 1987).
Self-efficacy theory as proposed by Bandura (1982) is
useful in understanding the cognitive mediators involved in
the chronic pain patient's avoidance of physical activity.
Self-efficacy is defined as an individual's belief in
his/her ability to perform a particular behavior. This
belief, in turn, can influence a certain outcome. For
example, Bandura (1982) suggests that thoughts about the
self mediate between knowledge of how to perform a behavior,
motivation to perform a behavior, and the actual performance


103
b.How many visits to a doctor's office have you made for
low back pain during the last 12 months?
c.How many times were you hospitalized for low back pain
during the last 3 years?
d.How many surgical procedures have you had for low back
pain?
e.How many chymopapain injections or other intradiscal
procedures have you had for low back pain?
f.Have you received any of the following treatments for
low back pain?
Nerve blocks Yes ( ) No ( )
Biofeedback Yes ( ) No ( )
Relaxation Techniques Yes ( ) No ( )
Psychotherapy Yes ( ) No ( )
Electrical nerve stimulation Yes ( ) No ( )
Acupuncture Yes ( ) No ( )
Chiropractic manipulation Yes ( ) No ( )
Hypnosis Yes ( ) No ( )
Exercise Yes ( ) No ( )
Traction Yes ( ) No ( )
Back brace Yes ( ) No ( )
Pain treatment center Yes ( ) No ( )
Whirlpool Yes ( ) No ( )
Ultrasound Yes ( ) No ( )
Massage Yes ( ) No ( )
Vitamin or nutritional therapy Yes ( ) No ( )
Body cast Yes ( ) No ( )
Other Yes ( ) No ( )
Specify


4
disruptions, and those patients who are dysfunctional, as
exhibiting a "chronic pain syndrome."
The chronic pain syndrome has been associated with
western medicine and industrialized civilizations. Waddell
(1987) commented that prior to modern medicine and
industrialization, the prevalence and incidence of back pain
was the same as it is now, but those individuals did not
stop daily activities or become permanently disabled. He
postulated that seeking health care for chronic pain is a
function of the individual's perception and interpretation
of physical symptoms and a function of the availability and
expectations of medical treatment. Hence, the chronic pain
syndrome has been associated with psychological distress,
depression, the experience of failed treatment
interventions, and a sick role adaptation; not as a response
to physiological activity.
There are many theories that attempt to describe and
define the chronic pain experience. The original theories
of pain were based on a somatosensory model. This model
postulated that feelings of pain were directly proportional
to peripheral damage (Blackwell, Galbraith, & Dahl, 1984;
Tursky, Jamner, & Friedman, 1982). However, current
theories of pain disagree with this model. More recent
theories propose that the subjective feeling of pain is not
directly related to tissue damage, but instead, results from
an interaction of physical, socio-environmental, and


13
therefore, attempts to extinguish pain behaviors by changing
the contingencies of reinforcement to well behaviors.
Specific goals of these physical-psychological
treatments are to reduce pain behaviors such as medication
use, inactivity, and verbal and nonverbal pain
communications (such as guarding and bracing). Medication
reduction is often achieved by administering "pain
cocktails" or by reinforcing patients in their own attempts
at reducing medication utilization. Low activity levels are
usually assessed by self-report measures of "up-time" (time
that the patient is not in a reclined position). Some
studies report more objective measures of assessment such as
video taping while the patient engages in various activities
(e.g., sitting, standing, and walking). Treatment
interventions for activity levels most often include
reinforcement for up-time. Patients are encouraged to
gradually increase their time out of bed, walking, and doing
various activities. Patients' perceived ability to perform
increased activity levels are also encouraged and reinforced
through their participation in general physical therapy
modalities. Treatment for verbal and nonverbal pain
behavior is usually accomplished by ignoring inappropriate
behaviors (body postures or verbal complaints) and
reinforcing appropriate behaviors. Hence, the physical
component to these treatment programs relies heavily on the
psychological concept of operant conditioning.


71
Again, the treatment group decreased their pain reports
while the control group reported even higher levels of pain
at the end of the study. Changes in pain and physical
dysfunction were hypothesized to result in decreases in
psychological distress (depression, anxiety, and stress),
but the findings of this study did not support this
hypothesis. Subjects in this study reported significantly
high levels of depression, anxiety, and stress prior to
entering the protocol and at the end of treatment, both
groups continued to report significantly high levels of
psychological distress.
It was hypothesized that pre-treatment measures of
self-efficacy, pain, and perceived social support would be
related to adherence to the treatment program and to
therapeutic gains. All but one subject completed the
treatment program; therefore, attrition could not be
investigated. With respect to predicting treatment outcome
from pre-treatment measures of pain, activity levels, self-
efficacy, and social support; pre-treatment pain was most
predictive of post-treatment strength changes.
Additionally, there was a strong relationship between
changes in strength and perceived self-efficacy (as measured
by the Internal Locus of Control subscale of the Exercise
Objectives Locus of Control Scale). Contrary to the
original hypotheses, social support was not related to
treatment outcome measures.


52
After the fourth session, subjects were randomly
assigned to a treatment condition which consisted of 14
exercise sessions or to a ten week wait-list control group.
Random assignment of the first 55 eligible patients resulted
in 32 subjects being assigned to the treatment group and 23
to a wait-list control group.
Before the fourth Medx session, subjects were re
administered the EOLCS and the pain rating scale. This
enabled the investigators to evaluate the effects of
exposure to the training machine.
Experimental Group
Subjects began exercising on the MedX lumbar
extension machine twice per week for six weeks followed by
one day per week for an additional six weeks. MedX
training consisted of variable resistant isotonic exercises
at a work load of 1/2 the subject's peak isometric strength.
At the end of 12 weeks, subjects were re-tested for lumbar
extension strength and the self-report questionnaires were
completed (treatment history, EOLCS, WHYMPI, MHI, PSS, SIP,
and activity questionnaire).
Wait-List Control Group
This group of subjects received the same complete
medical evaluation, MedX orientation, and MedX lumbar
strength testing as the experimental group. They also
completed all questionnaires prior to exposure to the MedX
lumbar extension machine. They then repeated the EOLCS and


LUMBAR STRENGTHENING IN CHRONIC LOW BACK PAIN PATIENTS:
PSYCHOLOGICAL AND PHYSIOLOGICAL BENEFITS
BY
SHERRY V. RISCH
A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL
OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE OF
DOCTOR OF PHILOSOPHY
UNIVERSITY OF FLORIDA
1990
UKIVFP'


Physiological Findings
Subjects were tested for isometric strength of the
72
lumbar extensor muscles on the MedX lumbar extension
machine at the beginning and end of this 12 week treatment
protocol. Due to the chronicity and physical limitations of
this sample, many of the subjects were unable to complete a
full 72 degrees range of motion. In fact, 75% of the
population could not flex at the 72 degree angle and 35%
could not flex at 60 degrees. Despite these limitations in
range of motion, statistical analysis resulted in finding
that the treatment group as compared to the control group
significantly increased in their generated torque values
following only 14 exercise sessions over a 10 week period.
The statistics used to assess strength changes pre- and
post-treatment standardized the data for group comparisons.
Given that subjects could not complete a full range of
motion, isometric testing points varied a few degrees across
subjects within their differing abilities. Hence,
regression equations were computed for each subject pre- and
post-treatment and the resultant slopes and intercepts of
the regression lines were utilized for measuring change.
Results of the statistical analysis indicated that there
were no differences between groups in the slopes of the
regression line pre- or post-treatment. However, the
control group failed to generate a straight line and
exhibited a marked deviation at the 72 degree angle. Given


19
Therefore, in order to better understand the effects of
these treatment programs, there is a need for studies to be
conducted within an experimental design (Tan, 1982).
Recent studies contend that the important element in
the treatment of chronic low back pain patients is increased
functional strength. Quantitative strength changes and
physical improvement have been postulated to be important
for surgical decisions, designing rehabilitation techniques,
and for disability determinations (Mayer et al., 1985).
Furthermore, treatment programs that offer passive treatment
modalities (i.e., spinal manipulation, electrical
stimulation, and biofeedback) potentially increase a
patient's dependence on the health care system and
potentiate their manifestation of the sick role. Given the
complexity of these multidisciplinary treatment programs,
evaluation of successful treatment is difficult in that it
incorporates medical, legal, psychological, and
socioeconomic problems. One of the most current assertions
is that the major deficit in chronic low back pain is a
physical deficit from muscular disuse caused by prolonged
and excessive protection of the spine (Mayer et al., 1987).
Hence, there is a strong need for future research to address
the relative importance of the various therapeutic elements
(i.e., physical and psychological therapies) offered in the
multidisciplinary treatment programs (Hazard, Fenwick,
Kalish, Redmond, Reeves, Reid, & Frymoyer, 1989; Mayer et


108
8.How many different drugs have you taken in the last month?
1. Name the first drug
How many days a week do you take this drug?
How many time a day do you take it?
2. Name the second drug
How many days a week do you take this drug?
How many time a day do you take it?
3. Name the third drug
How many days a week do you take this drug?
How many time a day do you take it?
4. Name the fourth drug
How many days a week do you take this drug?
How many time a day do you take it?


29
(pain) and emotional reactions (such as stress and anxiety).
Hence, psychological distress may precipitate low back pain
by creating muscle tension in the weaker spinal muscles. If
these weaker, but tense muscles are subjected to a work
load, the individual may then experience pain. Therefore, a
pain-stress cycle can begin with pain, or stress itself can
be a precipitating factor (Keefe & Gil, 1986; Linton, 1987).
Although the experimental findings on the relationship
between pain and stress with respect to chronic pain is
inconclusive, there is some evidence that individuals
manifest specific physiological responses to perceived
stress (Flor & Turk, 1989).
The pain-stress model suggests that psychological
distress can exacerbate pain in weaker muscle groups, and
that weak and painful muscles can exacerbate psychological
distress. Bortz (1984) suggested that "use" is a biological
principle inherent in all species and that inactivity
results in the muscles stiffening and decreasing in fiber
diameter which results in muscular atrophy. Hence, chronic
pain may be viewed as a "disuse syndrome". If muscular
atrophy and psychological distress contribute to the
experience of low back pain, treatment of the chronic low
back patient should address both areas. The studies
reviewed above share a focus on improving the chronic pain
patient's psychological and functional status by increasing
their activity levels. Hence, physical reconditioning with


73
the small sample size at this angle (18% of the control
group) and the variability in the torque values generated,
it could be assumed that this is a measurement error and not
indicative of a non-linear relationship. Additionally, when
the slopes of the strength curve are compared ranging to
only 60 degrees of flexion (72% of the total sample), the
discrepancy in the linear relationship is no longer evident.
Based on the findings that the slopes of the isometric
strength curves were similar pre- and post-treatment,
comparisons were performed between groups on changes in the
intercept. There were no pre-treatment differences between
the intercepts of the control group and the treatment group.
Results suggest that the control group was stronger pre
treatment at the 60 degree angle. Again, given the smaller
sample size and the increased variation in torque values at
this angle, these findings may also be an artifact of
measurement. On the other hand, given that the control
group's post-wait testing remained higher than the treatment
group's pre-treatment testing, the control group may have
been stronger at this measurement point. Nevertheless, the
decline in torque for the control group as compared to the
increase in torque for the treatment group support the
hypothesis that exercise on the MedX lumbar extension
machine increases lumbar extension strength. Analyses of
changes in intercept indicated that the treatment group
significantly changed their intercept scores as compared to


REFERENCES
Ackerman, M.D. and Stevens, M.J. (1989). Acute and chronic
pain: pain dimensions and psychological status. Journal
of Clinical Psychology. 76. 223-228.
Bandura, A. (1982). Self-efficacy mechanism in human
agency. American Psychologist. 37, 122-147.
Bandura, A., O'Leary, A., Taylor, C.B., Gauthier, J., and
Gossard, D. (1987). Perceived self-efficacy and pain
control: opiate and nonopioid mechanisms. Journal of
Personality and Social Psychology. 53, 563-571.
Bergner, M., Bobbitt, R.A., Pollard, W.E., Martin, D.P., and
Gilson, B.S. (1981). The sickness impact profile:
Validation of a health status measure. Medical Care. 14,
57-67.
Bigos, S.J. and Battie, M.C. (1987). Acute care to prevent
back disability. Ten years of progress. Clinical
Orthopaedics and Related Research. 221. 121-130.
Blackwell, B., Galbraith, J.R., and Dahl, D.S. (1984).
Chronic pain management. Hospital and Community
Psychiatry. 35, 999-1008.
Blair, S.N., Haskell, W.L., Ping Ho, Paffenbarger, R.S.,
Jr., Vranizan, K.M., Farquhar, J.W., and Wood, P.D.
(1985). Assessment of habitual physical activity by a
seven-day recall in a community survey and controlled
experiments. American Journal of Epidemiology. 122. 794-
804.
Block, A.R. (1982). Multidisciplinary treatment of chronic
low back pain: A review. Rehabilitation Psychology. 27,
51-63.
Bono, S.F. and Zasa, M.L. (1988). Chronic low back pain and
therapy: A critical review and overview. The Behavior
Therapist. 11, 189-198.
Bortz II., W.M. (1984). The disuse syndrome. The Western
Journal of Medicine. 141. 691-694.
89


30
exercise is a viable treatment modality with a chronic low
back pain population.
General Effects of Exercise on Psychological Functioning
In terms of psychological benefits, previous studies
suggest that physical exercise can decrease psychological
stress, anxiety, and depression in certain populations
(Dishman, 1985; Folkins & Sime, 1981; Keller & Seraganian,
1984; Levine, 1971; Reiter, 1981; Weisenberg, 1987). In
addition, physical fitness is proposed to enhance an
individual's ability to effectively manage emotional stress
and to improve adaptive interactions with the environment.
Improved cardiovascular functioning with exercise and
reduced resting muscle action potentials following exercise
are suggested to be associated with decreased tension and
psychological distress. Exercise is also purported to
provide an individual with a sense of mastery and control
which is then associated with feelings of psychological
well-being (Folkins & Sime, 1981).
However, there is inconsistency in the literature
regarding the specific psychological benefits of exercise,
and as Hughes (1984) suggests, many studies are quasi-
experimental and flawed with experimental biases. His
review of 12 studies which employed acceptable experimental
methodology, suggests inconclusive findings regarding the
effects of exercise on depression and anxiety. In keeping
with Hughes' (1984) review of a lack of consistent positive


42
an individual's performance in a given activity, and with
the finding that social reinforcement effects an
individual's pain coping abilities and adherence to exercise
programs. Given the hypothesis that patients avoid exercise
based on their negative past experiences, self-efficacy
beliefs were believed to contribute to the individual's
motivation to continue in a rigorous exercise program and
hence predict attrition (or treatment drop-outs).


This dissertation is dedicated to my husband, E. David
Risch, and my two children, Valerie and Kristopher, who have
encouraged and supported my efforts over the years,
faith and understanding will always be cherished.
Their


102
h.How many drinks do you have on a typical day?
Liquor Wine
Beer Other
i. Have you ever had any physical, psychological, social,
work-related, or legal problems because of alcohol?
Yes ( ) No ( )
j. How often do you take non prescription (over-the-
counter) drugs for pain relief?
7
days
a week
(
)
1 to 2 days
a week
(
)
5
to 6
days a
week
(
)
less than 1
day a week
(
)
3
to 4
days a
week
(
)
Never
(
)
12. Treatment History:
a. Have you ever consulted any of the following
specialists for low back pain before today?
Acupuncturist
Yes
(
)
No
(
)
Not
sure
(
)
Chiropractor
Yes
(
)
No
(
)
Not
sure
(
)
Faith healer
Yes
(
)
No
(
)
Not
sure
(
)
Family physician
Yes
(
)
No
(
)
Not
sure
(
)
General surgeon
Yes
(
)
No
(
)
Not
sure
(
)
Hypnotist
Yes
(
)
No
(
)
Not
sure
(
)
Internist
Yes
(
)
No
(
)
Not
sure
(
)
Neurologist
Yes
(
)
No
(
)
Not
sure
(
)
Orthopedist
Yes
(
)
No
(
)
Not
sure
(
)
Osteopath
Yes
(
)
No
(
)
Not
sure
(
)
Physical therapist
Yes
(
)
No
(
)
Not
sure
(
)
Psychiatrist
Yes
(
)
No
(
)
Not
sure
(
)
Psychologist
Yes
(
)
No
(
)
Not
sure
(
)
Rheumatologist
Yes
(
)
No
(
)
Not
sure
(
)
Other specialist


APPENDIX B
POST TREATMENT PATIENT QUESTIONNAIRE
Study #_
1. Name:
Last First Middle/maiden
2. How often do you have low back, buttock or leg pain?
7 days a week 1 to 2 days a week
5 to 6 days a week less than 1 day a week
3 to 4 days a week
3. On the days when you have pain, how many hours are you IN
PAIN during a 24-hour period?
4. On the days when you have pain, how many hours are you
FREE OF PAIN during a 24-hour period?
5. Since your initial evaluation, would you describe your
pain as:
Increased?
Decreased?
Same?
6. How often do you take non prescription (over-the-counter)
drugs for pain relief?
7
days
a week
(
)
1 to 2 days
a week
(
)
5
to 6
days a
week
(
)
less than 1
day a week
(
)
3
to 4
days a
week
(
)
Never
(
)
105


37
atrophy. They describe two muscle fiber types in the low
backfast and slow twitch fibers. The fiber types
determine not only the patient's strength, but their ability
to endure work-loads for varying lengths of time. Fast
twitch muscle fibers are suggested to fatigue much more
readily than slow twitch fibers which may predispose the
individual to reduced muscular strength and subsequently
lead to injury and pain. These investigators report that
based on endurance measures taken across a large healthy
sample, 30% of the general population has predominantly fast
twitch lower back muscles, 10% has predominantly slow
twitch, and 60% has a fairly even mixture of the two types
of fibers. Since a majority of the population has a
combination of fiber types, these authors suggest that
understanding of an individual's predominant fiber type
should be determined by computing a ratio of their lower
back muscles' strength to their endurance under a work load.
In summary, results of unpublished studies testing a
diverse population of subjects on the MedX lumbar
extension machine suggest that 30% of the general population
has a high percentage of fast twitch fibers and 60% has a
mixture of fast and slow twitch fibers. Based on these
studies, it is proposed that the lumbar extensor muscles are
proportionately weaker in the extended position and stronger
in the flexed. These authors further conclude that
individuals with predominantly high twitch muscle fibers


49
Mental Health Inventory
This measure was included to assess changes in overall
psychological well-being, and changes in anxiety and
depression. Factor analysis of the Mental Health
Inventory's (MHI) 38 questions indicates that there are two
higher order factors and five lower order factors (Veit &
Ware, 1983). The factor of psychological well-being is
defined by two lower order factors of General Positive
Affect and Emotional Ties. A second factor of psychological
distress is defined by three lower order factors of Anxiety,
Depression, and Loss of Behavioral/Emotional Control.
Additionally, a Life Satisfaction score is obtained. The
MHI is a good psychometric instrument with an internal
consistency reliability coefficient of 0.94 and a one week
test-retest reliability of 0.80 (Veit & Ware, 1983). The
two higher order factors were used in this study to assess
psychological well-being, and depression and anxiety.
Perceived Stress Scale
The Perceived Stress Scale (PSS, Cohen, Kamarck, &
Mermelstein, 1983) is a 14-item questionnaire used to
measure a general area of perceived stress. There are three
general subscales generated with this measure; physical
disability, psychosocial distress, and work/recreation
dysfunction. This measure was incorporated due to the
findings that chronic pain patients experience psychological
distress and to the belief that a particular event is not


21
of a behavior. If the patient believes that he/she is
incapable of completing a certain behavior/activity, the
activity will be avoided. Self-efficacy beliefs will
determine not only the performance of an activity, but also
the amount of effort an individual will expend and persist
in an activity. In summary, the individual's belief that
he/she can master a certain behavior will predict actual
performance of a given behavior. If self-efficacy
expectations are negative, performance will be impaired in
spite of functional abilities (Dolce, 1987).
Bandura has shown that the phobic patient's perception
(self-efficacy expectancies) of his/her ability to cope with
and master in-vivo exposure to feared stimuli are predictive
of the patient's actual behavioral performance. He found
that with gradual exposure to a feared stimulus, the phobic
patient's prior self-efficacy expectations predicted his/her
performance of previously avoided behaviors, and that as
he/she performed these avoided behaviors, self-efficacy
expectancies increased.
Self-efficacy expectations have not only been shown to
predict behavioral change in phobia patients, but they have
also been predictive of behavioral change in other patient
populations. For example, Ewart, Taylor, Resse, and DeBusk
(1983) studied 40 males referred for treadmill exercise
following a myocardial infarction. Self-efficacy was
measured by a self-report questionnaire that asked the


51
1985). For this population, validity of this measure was
found in significant correlations between up/down time, and
emotional distress as measured by the MMPI (0.29, Pearson
correlation coefficient, and 0.52-0.64 canonical variate
coefficients).
Procedures
Subjects were consecutively referred by an orthopaedic
surgeon for rehabilitation on the MedX lumbar extension
machine. All subjects received a complete medical
evaluation by the orthopaedic spinal specialist in order to
rule out the presence of organic pathology which would
require surgical intervention. Patient referrals were
informed that the exercise machine was involved in a
research protocol and were requested to participate. After
completing an informed consent, subjects completed the
demographic and self-report questionnaires. The
experimental protocol was approved by the institutional
review board of the University of Florida.
Subjects then returned for a baseline test followed by
two orientation and practice exercise sessions on the MedX
lumbar extension machine. These orientations provided the
subjects information on proper use of the equipment and
enabled the investigators to obtain reliable lumbar
extension force curves. Subjects then returned for a fourth
session and were tested for lumbar extension strength as was
previously described.


46
pain problem, the duration of their pain problem, previous
treatment interventions (i.e., prior hospitalizations,
surgeries, physical therapy modalities, and other
medical/psychological interventions), and current
medications. At the end of the study, subjects were
administered a second questionnaire to assess their
utilization of medical interventions during the study (See
Appendix A and B.).
Measures of self-efficacv
Exercise Objectives Locus of Control Scale. This
measure is a standardized instrument which was used to
assess the subject's perception of control over and ability
to master the MedX exercise regimen. The Exercise
Objectives Locus of Control Scale (EOLCS) was developed by
McCready and Long in 1985. The test has 18-items (e.g., My
own actions will determine whether or not I achieve my
exercise objectives) which are responded to on a scale of 1
to 5 (l=strongly agree, and 5=strongly disagree). Three
scores are obtained: an internal control factor, a powerful
other factor, and a chance control factor. These three
factors reflect the individual's perceived ability to master
an exercise objective and provided information as to their
perceived competence in completing the task. This test has
good psychometric properties and was normed on males and
females ranging from 17 to 55 years in age. Cronbach's
alphas were 0.86 for internal control, 0.79 powerful other,


86
would have tested at the standard angles through the full
range of motion (0 to 72 degrees) and a standard
multivariate analysis of variance could have been utilized.
The examination of differing exercise regimens on the
MedX lumbar extension machine would have also been
informative. Although previous research in healthy
individuals found that one exercise session per week was as
effective as two and three sessions per week, there is no
research addressing the effects of exercise frequency in a
chronic pain syndrome population (Graves et al., 1990). In
this study, all treatment subjects exercised twice a week
for six weeks followed by once a week for six weeks. Given
the chronicity of this samples disability, it can only be
speculated that exercise twice a week for the entire 12 week
treatment program may have resulted in even more dramatic
strength changes which may have potentially resulted in
beneficial changes in activities and psychological distress.
The current study demonstrated that the control group
increased in measures of pain and psychological distress
which suggests that the role of expectancy for getting
better may have influenced the outcome of the treatment and
control groups. The increased distress and pain evident in
the control group may have been a function of having to wait
for treatment. On the other hand, the increased pain and


22
patients to rate their self-perceived ability to perform
various activities (e.g., walking, running, and climbing
stairs). Self-efficacy was found to increase after
successful completion of treadmill exercise and was
predictive of the subject's participation in subsequent
activities such as walking, running, and climbing stairs.
Hence, enhanced self-efficacy expectations were
significantly correlated with the subject's actual intensity
and duration of subsequent physical activities. Along
similar lines, Manning and Wright (1983) found that self-
efficacy expectancies regarding an individual's perceived
ability to run a 10 Km race were more predictive of race
performance than the subject's actual running history.
Hence, the chronic pain patient's avoidance of physical
activity may not be in response to the experience of painful
sensations, but instead may be an avoidant coping mechanism
which is employed to reduce fear and anxiety associated with
activity.
Only a few studies have looked at the role of self-
efficacy expectations and the perception of pain. The role
of self-efficacy theory is important in that patients avoid
activities because pain signals a problem. Hence, the
patient develops avoidance behaviors independent of pain.
The impact of the patient's self-efficacy then is
determinant of their participation in treatment
interventions. For example, Kleinke & Spangle (1988) found


28
expectations are a useful predictor of pain coping behaviors
and of post-treatment maintenance of therapeutic gains
(Dolce et al., 1986a; Dolce et al., 1986b).
In conclusion, perceived control over a situation is
important when addressing the chronic pain patient's
motivation and ability to engage in exercise treatment
programs. Exercise is emphasized in the treatment of
chronic pain and is described as "well behavior. Efficacy
expectations are important considerations and effect how
much effort an individual will exert and how long they will
persist in the face of aversive experiences such as exercise
regimens or quotas that may initially exacerbate their
fears, anxieties, and pain.
Physical Reconditioning as a Wav of Improving
Muscular Strength and Psychological Symptoms
Sedentary life styles and the lack of physical fitness
have been proposed as causal agents in maintaining low back
pain (Rosomoff, 1985). Not only do chronic low back pain
patients suffer with the nociception of their original pain,
but their pain experience is exacerbated by muscle atrophy
resulting from subsequent inactivity. Similarly,
psychological distress may not only be a consequence of low
back pain, but also has a role in the exacerbation of
existing pain levels (Flor & Turk, 1989: Gottlieb et al.,
1977). According to the Gate Control Theory of pain, stress
can lead to increased autonomic arousal and increased muscle
activity. This in turn leads to peripheral stimulation


BIOGRAPHICAL SKETCH
Ms. Risch was born in Biloxi, Mississippi, on January
20, 1953. She is married to E. David Risch and has two
children, Valerie and Kristopher. While raising her family,
Sherry Risch has worked as a physician's assistant, a
comptroller for a large medical concern, a medical business
manager, and as a research coordinator.
Sherry Risch received her Associate of Arts degree in
June 1982 at St. Johns River Community College, Palatka,
Florida, graduating Magna Cum Laude. She attended the
University of Florida from August 1982 to December 1984 at
which time she was awarded her Bachelor of Science degree
and completed her honors thesis in diabetes melitis. Ms.
Risch was accepted into the Clinical and Health Psychology
Department's doctoral program in August 1985 and completed
her Master's degree in 1987. Her area of interest is in
medical psychology, and the focus of her research has been
in investigating the psychological correlates in chronic low
back pain patients. Ms. Risch plans to pursue a career of
both research and private clinical practice after
graduation.
109


39
machine for 10 weeks. Training produced significant
increases in lumbar extension strength, as well as decreases
in self-reported pain, and increases in functional status as
measured by the Oswestry Low Back Pain Disability
Questionnaire (MacMillan et al., 1988, unpublished data).
While this study suggests that lumbar extensor
strengthening may be beneficial in treating patient's with
chronic, mild, low back pain, there are several
methodological weaknesses. It is unclear how the term
"mild" low back pain was operationalized. It is also
unclear if mild represents limited pathophysiological
findings, limited psychological distress, or both. In
addition, a low back pain control group was not included.
Previous research suggests that the MedX lumbar
extension machine effectively strengthens lumbar extensor
muscles and that this strengthening is superior to other
methods of lumbar exercise for healthy individuals (Graves
et al., 1990; Pollock et al., 1989). In addition, pilot
data (MacMillan et al., 1988) suggests that exercise on the
MedX lumbar extension machine may be a beneficial
treatment modality for patients with mild, low back pain.
Since low back pain patients are a heterogeneous population
comprised of differing levels of physical, psychological and
social involvement with their pain, more research is needed
to investigate the benefits of the MedX lumbar extension
machine for these patients.


15
Many treatment programs emphasize a multimodal approach
to the treatment of chronic pain. These treatment protocols
include psychological, physical, and vocational
interventions. Such multidisciplinary interventions appear
to produce significant improvement in chronic pain patients.
In a review of multimodal treatment studies which included
follow-up, Block (1982) found that studies including a 10-
month follow-up reported an average of 58% of the subjects
had reduced their intake of analgesic medications. Other
improvements include 75% either employed or in employment
training programs, 70% with significantly increased activity
levels, and 74% received no additional treatment. Block
(1982) also reports that in studies with 3-year follow-up,
an average of 60% of the subjects had reduced their
analgesic medications, and 100% maintained increased
activity levels.
Although Block's (1982) review suggests that these
treatment programs are successful, the studies reviewed
provide only limited information in that they were quasi-
experimental. Additionally, patients participating in
multidisciplinary pain treatment centers are a select sample
and only represent a small percentage of individuals
suffering with chronic low back pain. Participation in
these multidisciplinary programs usually requires
authorization and payment by insurance companies (mostly
workmen's compensation) and is often contingent on the



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101
e. How often do you have low back, buttock or leg pain?
7 days a week 1 to 2 days a week
5 to 6 days a week less than 1 day a week
3 to 4 days a week
f. On the days when you have pain, how many hours are you
IN PAIN during a 24-hour period?
g. On the days when you have pain, how many hours are you
FREE OF PAIN during a 24-hour period?
11. Habits:
a. Do you currently smoke cigarettes? Yes ( ) No ( )
b. How many cigarettes do you smoke on a typical day?
None ( ) Less than 1 pack ( ) 1 to 2 packs ( )
More than 2 packs ( )
c. Do you currently smoke a pipe or cigars? Yes( ) No( )
d. How many cups of coffee (caffeinated only) do you
drink on a typical day?
None ( ) 1 to 2 cups ( ) 3 to 4 cups ( )
more than 4 cups ( )
e. How many cups of tea (caffeinated only) do you drink
on a typical day?
None ( ) 1 to 2 cups ( ) 3 to 4 cups ( )
more than 4 cups ( )
f. How many cans of soda (caffeinated only) do you drink
on a typical day?
None ( ) 1 to 2 cans (
more than 4 cans ( )
) 3 to
4 cans ( )
g. During a typical week, how
often do you drink
alcoholic beverages
(beer,
wine, liquor)?
7 days a week
( )
1 to 2 days a week
(
)
5 to 6 days a week
( )
less than 1 day a week
(
)
3 to 4 days a week
( )
Never
(
)