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Active rehabilitation for chronic low back pain: Cognitive-behavioral, physical, or both? First direct post-treatment results from a randomized controlled trial [ISRCTN22714229]

Rob JEM Smeets1*, Johan WS Vlaeyen2, Alita Hidding3, Arnold DM Kester4, Geert JMG van der Heijden5, Antonia CM van Geel1 and J André Knottnerus6

Author affiliations

1 Rehabilitation Centre Blixembosch, Eindhoven, and Netherlands School of Primary Care Research, University of Maastricht, The Netherlands

2 Department of Medical, Clinical and Experimental Psychology, University of Maastricht, The Netherlands

3 Department of Education & Research, Atrium Medical Centre, Heerlen, The Netherlands

4 Department of Methodology and Statistics, University of Maastricht, The Netherlands

5 Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, The Netherlands

6 Netherlands School of Primary Care Research, University of Maastricht, The Netherlands

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Citation and License

BMC Musculoskeletal Disorders 2006, 7:5  doi:10.1186/1471-2474-7-5

Published: 20 January 2006



The treatment of non-specific chronic low back pain is often based on three different models regarding the development and maintenance of pain and especially functional limitations: the deconditioning model, the cognitive behavioral model and the biopsychosocial model.

There is evidence that rehabilitation of patients with chronic low back pain is more effective than no treatment, but information is lacking about the differential effectiveness of different kinds of rehabilitation. A direct comparison of a physical, a cognitive-behavioral treatment and a combination of both has never been carried out so far.


The effectiveness of active physical, cognitive-behavioral and combined treatment for chronic non-specific low back pain compared with a waiting list control group was determined by performing a randomized controlled trial in three rehabilitation centers.

Two hundred and twenty three patients were randomized, using concealed block randomization to one of the following treatments, which they attended three times a week for 10 weeks: Active Physical Treatment (APT), Cognitive-Behavioral Treatment (CBT), Combined Treatment of APT and CBT (CT), or Waiting List (WL). The outcome variables were self-reported functional limitations, patient's main complaints, pain, mood, self-rated treatment effectiveness, treatment satisfaction and physical performance including walking, standing up, reaching forward, stair climbing and lifting. Assessments were carried out by blinded research assistants at baseline and immediately post-treatment. The data were analyzed using the intention-to-treat principle.


For 212 patients, data were available for analysis. After treatment, significant reductions were observed in functional limitations, patient's main complaints and pain intensity for all three active treatments compared to the WL. Also, the self-rated treatment effectiveness and satisfaction appeared to be higher in the three active treatments. Several physical performance tasks improved in APT and CT but not in CBT. No clinically relevant differences were found between the CT and APT, or between CT and CBT.


All three active treatments were effective in comparison to no treatment, but no clinically relevant differences between the combined and the single component treatments were found.