Joumal of P.~ychosomaric Research. Vol. 35. No 6, pp. 671-677. Printed in Great Br~tam
1991 0
0022-3999191 S3.00+ 40 1991 Pergamon Press plc
A CONTROLLED STUDY OF COUPLE THERAPY CHRONIC LOW BACK PAIN PATIENTS. NO IMPROVEMENT OF DISABILITY
IN
S. SAARIJ~RVI,U. RYT~KOSKI and E. ALANEN (Received
27 November
1990; accepted
in revised form
4 April
1991)
Abstract-Family-oriented approaches and consequent conjoint marital sessions have been widely accepted as ingredients of comprehensive treatment and rehabilitation of chronic pain patients. However, no controlled trials have been conducted to confirm the effectiveness of couple therapy in these patients. We examined 63 chronic low back pain (CLBP) patients identified in primary health care centres. They were randomly allocated to a couple therapy group (n = 33) and to a control group without couple therapy (n = 30). The therapy consisted of five monthly sessions and was attended by two family therapists. All patients attended an initial examination and a 12-month follow-up examination. Effects on self-reported pain, disability, and some clinical measures, as well as on the use of medical services were evaluated. The study groups did not differ significantly in any of the outcome measures. Hence, we conclude that couple therapy has no significant effects on disability in CL,BP patients.
INTRODUCTION
low back pain (CLBP) is a complex biopsychosocial problem. Thus, there is an urgent need to develop new treatment modalities combining medical and psychological approaches [ l-31. A new field of research is the relation between the family and chronic pain [ 1-71. Most studies with spouse involvement have been carried out on patients seeking help in pain clinics. The patient selection may then bias the outcome, because persistent pain sufferers from pain clinics and family practices have been shown to differ in many pain behavior and emotional variables, and those from family practices have usually shown a better prognosis than those from pain clinics 181. Furthermore, referral patterns, failure to enter treatment, and attrition have caused serious problems in chronic pain treatment outcome studies conducted in pain clinics [91. Another serious problem of conjoint marital sessions is the lack of adequately designed randomized trials, making the validity and reliability of outcome measures questionable. When interactional marital therapy is the method of intervention, the outcome measures should also be adequate for measuring possible changes in interaction. The purpose of this comprehensive, controlled, prospective study was to assess the effects of couple therapy in CLBP patients recruited from primary health care centers. We recently showed that couple therapy improves marital communication in chronic low back pain patients thereby enhancing their quality of life [lOI. The same couples underwent further examinations to evaluate the effects of couple therapy on disability, which has been defined according to WHO as ‘any restriction or lack (resulting from an impairment) of ability to perform an activity in the manner or within the range considered normal for a human being’ [ 111. CHRONIC
The Rehabilitation Finland.
Research
Centre of the Social Insurance
671
Institution,
Peltolantie
3, SF-20720
Turku,
612
S. SAARIJKRVI et al METHOD
Subjects
Patients with CLBP were originally recruited from municipal primary health care centers in the city of Turku. They had earlier participated in a study on the effectiveness of a modified Swedish back school Il21. The present study was carried out in combination with a one year follow-up of the previous study. The CLBP patients were seen at the Rehabilitation Research Centre (RRC) of the Social Insurance Institution in Turku. An experienced physiatrist (specialist in physical medicine and rehabilitation) and a physiotherapist examined all CLBP patients who were asked to enrol in the present study together with their spouses. The patients were fully informed about the nature of the study protocol, which had been approved by the Ethical Committees of the Turku University Central Hospital and the RRC. Any family problems or the etiology of CLBP did not influence patient selection. The inclusion criteria were: (1) the CLBP patients was married and/or cohabiting with his/her spouse; (2) CLBP was still a persistent problem causing difficulty in daily activities according to the patient’s own report; (3) the patient had not recently been operated on for a herniated lumbar disc; and (4) the patient or the spouse had no disease causing more disability or handicap than the CLBP.
A total of 175 CLBP patients were seen at the RRC, and 98 of them met the above inclusion criteria. In 63 couples both spouses were willing to participate, whereas 35 couples refused. The compliant patients were randomized by stratification on gender, age (above or below 45 yr), and the intensity (two or ten sessions) of a previous Swedish back school [ 121. Thirty-three CLBP patients were assigned to a therapy (T) group, and 30 CLBP patients to a control (C) group. Four couples discontinued therapy after the first session and were regarded as drop-outs. Thus, the final analysis included 29 CLBP patients in the T-group, and 30 CLBP patients in the C-group. It was performed two years after the Swedish Back School and six months after the couple therapy. Demographic and clinical data of the CLBP patients, including age distribution, duration and diagnosis of low back pain, and sociodemographic variables have been presented in the previous paper [ 101. No significant differences were observed between the study groups in those variables. We also showed that couple therapy enhanced the quality of lie of the patients in the T-group by improving their marital communication, which worsened in the CLBP patients belonging to the C-group 1101.
The theoretical basis of the couple therapy was the family systems approach, which emphasizes the relational structure, hierarchical organization, boundary characteristics, and equilibrium maintenance of the family [ 131. Five sessions were conducted according to the systemic guiding principles of neutrality, hypothesizing and circularity [141. Interventive interviewing, i.e. active questioning, was the main therapeutic method I 151. Both therapists (male and female) asked questions and listened, changing roles from an active questioner to a passive listener. This method was thought of as a model of communication for the couple. Symptoms or other aspects of the illness were not the main focus of the interviews. However, the sessions were usually started with questions about the current state of health of both spouses; it was then easy to move on to other issues. The unique features of each couple’s relationship were emphasized in the feedback comments by the therapists. Positive connotation [ 141 was used especially during the last session. All couples were seen five times at intervals of about one month. Each session lasted 1-2 hr. A lo-15 min interval was held during each session. The same therapists conducted all sessions. The details of the therapy procedure have been described elsewhere [161.
Puin measures. A pain index (PI) was constructed from the Standardized Nordic Questionnaire (SNQ), designed for the analysis of musculoskeletal symptoms [ 171. The occurrence of self-reported pain in the neck, shoulders, elbows, arms, upper back, lower back, hips, knees and ankles during the past 7 days was covered. The alternative answers were 0 = no pain and 1 = pain. The range of the index was from 0 to 9. An impairment index (II) was also constructed from the SNQ and questions were asked about the same sites as above. The subjects were asked to report if those pains had caused any restrictions in their daily activities (at or outside home) during the last 6 months. The possible answers were 0 = no restrictions, and 1 = some restrictions. The range of the index was from 0 to 9. Disability measures. The Activities of Daily Living (ADL) index was a reduced version of the ADL index used by Alaranta [ 181. The items were the following: getting out of bed, washing, toenail care, putting on socks or tights, sitting for at least half an hour, and walking outdoors. The range of the total
Couple
therapy
in CLBP
patients
673
scores was from 0 to 12 points, in which 0 = no difficulties, 1 = some difficulties, 2 = no coping at all. The functional capacity index (FI) was based on patient self-reported assessment of functional capacity of his/her back at the time of the study: 1 = no difficulty with heavy workloads; 2 = difficulty only with heavy workloads; 3 = difficulty with moderate workloads; 4 = difficulties with light workloads; and 5 = continuous difficulty even at rest. Every alternative was illustrated with examples from everyday life. The range of the index was from 0 to 5. Clinical
examinations
The physiatrist’s examination (PE) included 12 functions: arm function; shoulder muscles; low back mobility; back muscles; gluteal muscles; leg muscles; hip and knee function as well as sitting, standing, undressing and walking. All functions were assessed as: 0 = normal; 1 = slight difficulty; 2 = moderate difficulty; 3 = severe difficulty. The scores of this index ranged from 0 to 3. The physiotherapist assessed pain and tenderness during the examination (PTE) of low back mobility (at discus levels L5-Th7). The following scores were used: 0 = no pain and tenderness; 1 = mild pain and tenderness; 2 = severe pain and tenderness. The range of the index was from 0 to 2. The same physiatrist and physiotherapist carried out examinations at the beginning and at the followup of the study. They were blind to the group assignment of the patients. Data nnaiy.sis The LISREL model [ 191, (Fig. 1) was used to analyze correlationicovariance groups at the beginning of the study and at the 12.month follow-up.
[
structures
Painindex
of the study
(es,
jlmpairmentindex+eZ
EXAMINATIONS
FIG. 1 shows
the LISREL-model,
e = measurement
error.
The model was intended to show relations between pain, disability and clinical measures at the beginning of the study and at the If-month follow-up study, as well as to describe the stability and reliability of the measures. The parameters of the model were estimated by the principle of the least squares, assuming that the qualities of each measure (e.g. reliability) remained unchanged during the one-year study period. Furthermore, the General Linear Model (GLM) of the SAS software system [201 was used for testing the mean effects of the treatment. Multivariate analysis of variance (MANOVA) for repeated measures was used for assessing changes in pain, disability and clinical measures. Univariate analysis of variance (ANOVA) was used to test the treatment effect on the use of medical services. A value of p < 0.05 was considered to be significant.
RESULTS
According to the LISREL model, reliabilities of the measures were the following: PI 0.81, II 0.89, ADL 0.76, FI 0.58, PE 0.79 and PTE 0.49.
S.
674
SAARUARW
Table I shows correlations between pain, beginning of the study and at the follow-up TABLE l.-CORRELATIONS Therapy
et al disability and clinical in both groups.
measures
at the
BETWEEN PAIN, DISABILITY AND CLINICAL. MEASURES
group:
P/l D/l C/l PI12 D/12 c/12
P/l 1.00 0.05 0.31 0.60 0.05 0.31
D/l
C/l
Pi12
D/l2
Cl12
I .oo 0.24 0.71 1.oo*
1 .oo 0.36 0.24
1.00 0.71
1 .oo
P/l 1.00 0.43 0.42 0.87 0.20 0.25
D/l
C/l
PI12
D/l2
c/12
I .oo 0.09 0.33 0.72 -0.08
1 .oo 0.37 0.17 0.82
1.00 0.42 0.53
1.00 0.18
I .OO
1 .oo 0.71 0.36 1 .oo* 0.71
* = fixed values Control P/l D/l Cl1 PI12 D/l2 Cl12
group:
P = pain measures. D = disability measures, C = clinical measures. The matrix shows correlation coefficients between the above measures and at the 12.month follow-up.
at the beginning
of the study
It is seen that correlation coefficients between pain, disability and clinical scores were high, indicating the stability of the measures in both groups during the study year. In the therapy group, correlation coefficients between initial and follow-up disability and clinical measures, respectively, became slightly greater than 1.OO. This indicates that one factor was not sufficient to explain the relation between the two measures. In other words, the residual variances included measurement-specific variation and measurement errors. Therefore, these correlation coefficients were fixed at 1 .OO in the final LISREL model, (see Table I). The goodness of the fit index of the model was then 0.98. The scattergrams for initial and follow-up measures of pain are plotted in Figs 2 and 3. 12 lo-
&
0
FIG. 2. Shows pain measures
2
in the therapy
4
6
6
group at the beginning follow-up ( = y).
10
12
of study ( = x) and at the 12.month
Couple
FIG. 3. Shows
pain measures
therapy
in CLBP
patients
in the control group at the beginning 12.month follow-up ( = y).
67.5
of the study
( = x) and at the
Pain measures were initially higher in the therapy group than in the control group (p = 0.04, MANOVA). No significant initial differences between the study groups were noted in disability and clinical measures. Outcome
effects
No significant gender differences were found in any of the measures used in the present study. No significant outcome effects (MANOVA) were observed in pain, disability or clinical measures during the study year (Table II). TABLE
II.-OUTCOME
Pre Mean (SD)
Post Mean (SD)
29 30
6.79 5.13
(2.64) (2.96)
5.93 4.87
(2.75) 2.76)
29 30
7.55 5.63
(2.57) (3.05)
6.62 5.27
(2.77) (2.97)
29 30
3.97 3.50
(2.06) (2.06)
4.10 3.83
(2.01) (2.00)
29 30
3.52 3.30
(1.09) (0.79)
3.52 3.13
(1.06) (0.90)
29 30
0.80 0.73
(0.32) (0.26)
0.59 0.55
(0.29) (0.24)
29 30
0.45 0.33
(0.45) (0.37)
0.59 0.34
(0.56) (0.33)
29 30
2.38 1.77
(2.97) (2.35)
2.21 1.03
(2.62) (1.30)
29 30
24.3 16.1
(35.8) (31.8)
20.3 19.3
(26.2) (49.8)
n
Pain index T-group c-group Impairment index T-group c-group ADL index T-group C-group Functional capacity index T-group C-group Physiatrist’s examination T-group c-group Physiotherapist’s examination T-group C-group Visits to physician T-group c-group Sick-leave days T-group c-group T = therapy
group,
C = control
MEASURES
group
676
The groups
S. SAARIJ~RVI et al.
did not differ (ANOVA)
in the use of medical
services
(Table
II).
DISCUSSION
To our knowledge, our study is the first randomized controlled study on the effectiveness of couple therapy in CLBP patients drawn from community health care centers. The poor validity and reliability of measures has been one serious obstacle in chronic pain treatment outcome studies. It is not always clear whether the changes reflected in the correlations are due to the treatment or simply artifacts due to pool stability or low reliability or a mixture of both during the course of the follow-up study. In this study efforts were made to overcome the common problems of statistical analysis in therapy studies. Most of the measures used in the study were found highly reliable and stable in statistical analysis. Disability was assessed in terms of pain and disability measures as well as results of clinical examinations and use of medical services. No significant changes were seen in single functional and mainly physical measures during the one-year study period either in the treatment or in the non-treatment control group. Only a slight decreasing tendency in pain complaints was noted in the treatment group. We recently showed that couple therapy improves marital communication of CLBP patients [lo] with a positive effect on social integration handicap (‘the individual’s ability to participate in and maintain customary social relationships’) [l 11 associated with chronic low back pain. We then assumed that the improved communication of CLBP patients could be reflected as a decrease in their pain complaints. This hypothesis was not confirmed by the present study conducted with the same couples. One possible explanation to negative findings might be the lack of severe marital problems [2 I I. In addition the previous Swedish Back School may have left little room for further improvement of the chronic pain. Me&analysis of non-medical treatments for chronic pain has shown that psychological therapies can relieve pain-related distress while the pain itself remains unchanged [221. Szasz suggested that chronic pain and especially complaints of pain may have a non-verbal communicative function which is impossible to express by other means [231. Our present empirical results support these two assumptions. The duration of follow-up may be critical for the interpretation of results. Many outcome studies of psychological therapies have been based on very short follow-up periods; usually only the immediate outcomes after the end of therapy have been reported. In this study the follow-up examinations took place six months after the couple therapy. The timing of follow-up assessments were chosen according to the recommendations of marital therapy and pain researchers [22, 24, 251. However, it is very difficult to conclude from previous empirical reports whether the therapy effect can be lost in one year or whether observation time of one year was too short to uncover changes in the disability of chronic pain patients. We assume that improved marital communication can relieve pain experience in due course. To test this hypothesis a five year follow-up study of these same CLBP patients is currently taking place. With the above reservations we conclude that, although couple therapy improves
Couple
therapy
in CLBP
patients
marital communication [ 101, it does not alter significantly disability in CLBP patients drawn from the community
617
self-reported and assessed health care centers.
Acknowledgements-We would like to thank Drs M.T. Hyypl and V. Lehtinen for their advice during the preparation of this paper. The study was supported by a grant from the Social Insurance Institution, Finland.
REFERENCES I.
2. 3. 4. 5. 6. 7. 8. 9. 10. II. 12. 13. 14. 15. 16. 17.
18.
19.
20. 21. 22. 23. 24. 25.
TURK DC, FI.OR H. Etiological theories and treatments for chronic back pain. II. Psychological models and interventions. Pain 1984; 19: 209-233. TURK DC, FL.OR H. RUDY TE. Pain and families. I. Etiology. maintenance, and psychosocial impact. Pain 1987; 30: 3-27. TURK DC, MEICHENBA~JM D. C&NEST M. Pain and Behavioral Medicine: A Cognitive-Behavioral Perspective. New York: Guilford Press, 1983. FLOR H, TURK DC, RUDY TE. Pain and families. II. Assessment and treatment. Pain 1987; 30: 29-45. FORDYC~ WE. Behavioural Methods for Chronic Pain and Illness. St. Louis: Mosby, 1976. PAYNE B, NORFLEETMA. Chronic pain and the family. A Review. Pain 1986; 26: l-22. ROY R. Marital and family issues in patients with chronic pain. Psychother Psychosom 1982; 37: I-12. CROOK .I, WEIR R. TUNKS E. An epidemiological follow-up of persistent pain sufferers in a group family practice and specialty pain clinic. Pain 1989; 36: 49-61. TURK DC, RUDY TE. Neglected factors in chronic pain treatment outcome studies - referral patterns, failure to enter treatment, and attrition. Pain 1990; 43: 7-25. SAARIJ~RVI S. A controlled study of couple therapy with chronic low back pain patients. Effects on marital satisfaction, psychological distress and health attitudes. / Psychosom Res 1991; 35: 265-272. International classification of impairments, disabilities and handicaps. World Health Organization. Geneva, 1980. ZACHRISSON FORSSEL M. The Swedish Back School. PhJsiotherupy 1980; 66: 112-I 14. BI.OTH DA. The family as a psychosocial system. Fern SystMed 1984; 2: 387-396. SELVINI-PAI.AZZOI.I M, BOSCOLO L, CECCHIN G, PRATA G. Hypothesizing-circularity-neutrality: Three guidelines for the conductor of the session. Fumily Process 1980; 19: 3-12. TOMM K. Interventive interviewing: II. Reflexive questioning as a means to enable selfhealing. Fami/y Process 1987; 26: 167-183. SAARIJAVI S, LAHTI T, LAHTI 1. Time-limited structural couple therapy with chronic low back pain patients. Fam Sysr Med 1989; 7: 328-338. KUORINKA I, JONSSON B, KII.BOM A, VINTERBERGER H, BIERINCER-SORENSEN F, ANDERSSON G, JBRGENXN K. Standardized Nordic questionnaires for the analysis of musculoskeletal symptoms. Appl Ergonomics 1987; 18: 233-237. ALARANTA H. Factors defining impairment, disability and handicap in a population of patients examined one year following surgery for lumbar disc herniation. Turku: Publications of the Social Insurance Institution, Finland, AL:25, 198.5. In Finnish with an English summary. JBRESKOG KG, S~RBOM D, LISREL V. Analysis of linear structural relationship by maximum likelihood and least squares methods. Research Report 81-8. University of Uppsala, Department of Statistics, 1981. SAS User’s Guide: Statistics, Version 5 Edition. Gary, NC: SAS Institute Inc., 1985. SAARIJ~VI S, HYYPPX MT, LEHTINEN V, AL.ANEN E. Chronic low back pain patient and spouse. J Psychosom Res 1990; 34: 117-122. MALONE MD, S-~RUBS MJ. Meta-analysis of non-medical treatments for chronic pain. Pain 1988; 34: 23 l-244. SZASZ T. Pain and pleasure. A Srudy ofBodily Feelings (2nd ed.). New York: Basic Books, 1975. HAZELRIGC MD, COOPER HM, BORDUIN CM. Evaluating the effectiveness of family therapies: an integrative review and analysis. Psycho/ Bull 1987; 101: 428-442. WHISMAN MA, JACOBSONNS, FRUZETTI AE, WALTZ JA. Methodological issues in marital therapy. Adv Behav Res Ther 1989; 11: 175-189.
1991 0
0022-3999191 S3.00+ 40 1991 Pergamon Press plc
A CONTROLLED STUDY OF COUPLE THERAPY CHRONIC LOW BACK PAIN PATIENTS. NO IMPROVEMENT OF DISABILITY
IN
S. SAARIJ~RVI,U. RYT~KOSKI and E. ALANEN (Received
27 November
1990; accepted
in revised form
4 April
1991)
Abstract-Family-oriented approaches and consequent conjoint marital sessions have been widely accepted as ingredients of comprehensive treatment and rehabilitation of chronic pain patients. However, no controlled trials have been conducted to confirm the effectiveness of couple therapy in these patients. We examined 63 chronic low back pain (CLBP) patients identified in primary health care centres. They were randomly allocated to a couple therapy group (n = 33) and to a control group without couple therapy (n = 30). The therapy consisted of five monthly sessions and was attended by two family therapists. All patients attended an initial examination and a 12-month follow-up examination. Effects on self-reported pain, disability, and some clinical measures, as well as on the use of medical services were evaluated. The study groups did not differ significantly in any of the outcome measures. Hence, we conclude that couple therapy has no significant effects on disability in CL,BP patients.
INTRODUCTION
low back pain (CLBP) is a complex biopsychosocial problem. Thus, there is an urgent need to develop new treatment modalities combining medical and psychological approaches [ l-31. A new field of research is the relation between the family and chronic pain [ 1-71. Most studies with spouse involvement have been carried out on patients seeking help in pain clinics. The patient selection may then bias the outcome, because persistent pain sufferers from pain clinics and family practices have been shown to differ in many pain behavior and emotional variables, and those from family practices have usually shown a better prognosis than those from pain clinics 181. Furthermore, referral patterns, failure to enter treatment, and attrition have caused serious problems in chronic pain treatment outcome studies conducted in pain clinics [91. Another serious problem of conjoint marital sessions is the lack of adequately designed randomized trials, making the validity and reliability of outcome measures questionable. When interactional marital therapy is the method of intervention, the outcome measures should also be adequate for measuring possible changes in interaction. The purpose of this comprehensive, controlled, prospective study was to assess the effects of couple therapy in CLBP patients recruited from primary health care centers. We recently showed that couple therapy improves marital communication in chronic low back pain patients thereby enhancing their quality of life [lOI. The same couples underwent further examinations to evaluate the effects of couple therapy on disability, which has been defined according to WHO as ‘any restriction or lack (resulting from an impairment) of ability to perform an activity in the manner or within the range considered normal for a human being’ [ 111. CHRONIC
The Rehabilitation Finland.
Research
Centre of the Social Insurance
671
Institution,
Peltolantie
3, SF-20720
Turku,
612
S. SAARIJKRVI et al METHOD
Subjects
Patients with CLBP were originally recruited from municipal primary health care centers in the city of Turku. They had earlier participated in a study on the effectiveness of a modified Swedish back school Il21. The present study was carried out in combination with a one year follow-up of the previous study. The CLBP patients were seen at the Rehabilitation Research Centre (RRC) of the Social Insurance Institution in Turku. An experienced physiatrist (specialist in physical medicine and rehabilitation) and a physiotherapist examined all CLBP patients who were asked to enrol in the present study together with their spouses. The patients were fully informed about the nature of the study protocol, which had been approved by the Ethical Committees of the Turku University Central Hospital and the RRC. Any family problems or the etiology of CLBP did not influence patient selection. The inclusion criteria were: (1) the CLBP patients was married and/or cohabiting with his/her spouse; (2) CLBP was still a persistent problem causing difficulty in daily activities according to the patient’s own report; (3) the patient had not recently been operated on for a herniated lumbar disc; and (4) the patient or the spouse had no disease causing more disability or handicap than the CLBP.
A total of 175 CLBP patients were seen at the RRC, and 98 of them met the above inclusion criteria. In 63 couples both spouses were willing to participate, whereas 35 couples refused. The compliant patients were randomized by stratification on gender, age (above or below 45 yr), and the intensity (two or ten sessions) of a previous Swedish back school [ 121. Thirty-three CLBP patients were assigned to a therapy (T) group, and 30 CLBP patients to a control (C) group. Four couples discontinued therapy after the first session and were regarded as drop-outs. Thus, the final analysis included 29 CLBP patients in the T-group, and 30 CLBP patients in the C-group. It was performed two years after the Swedish Back School and six months after the couple therapy. Demographic and clinical data of the CLBP patients, including age distribution, duration and diagnosis of low back pain, and sociodemographic variables have been presented in the previous paper [ 101. No significant differences were observed between the study groups in those variables. We also showed that couple therapy enhanced the quality of lie of the patients in the T-group by improving their marital communication, which worsened in the CLBP patients belonging to the C-group 1101.
The theoretical basis of the couple therapy was the family systems approach, which emphasizes the relational structure, hierarchical organization, boundary characteristics, and equilibrium maintenance of the family [ 131. Five sessions were conducted according to the systemic guiding principles of neutrality, hypothesizing and circularity [141. Interventive interviewing, i.e. active questioning, was the main therapeutic method I 151. Both therapists (male and female) asked questions and listened, changing roles from an active questioner to a passive listener. This method was thought of as a model of communication for the couple. Symptoms or other aspects of the illness were not the main focus of the interviews. However, the sessions were usually started with questions about the current state of health of both spouses; it was then easy to move on to other issues. The unique features of each couple’s relationship were emphasized in the feedback comments by the therapists. Positive connotation [ 141 was used especially during the last session. All couples were seen five times at intervals of about one month. Each session lasted 1-2 hr. A lo-15 min interval was held during each session. The same therapists conducted all sessions. The details of the therapy procedure have been described elsewhere [161.
Puin measures. A pain index (PI) was constructed from the Standardized Nordic Questionnaire (SNQ), designed for the analysis of musculoskeletal symptoms [ 171. The occurrence of self-reported pain in the neck, shoulders, elbows, arms, upper back, lower back, hips, knees and ankles during the past 7 days was covered. The alternative answers were 0 = no pain and 1 = pain. The range of the index was from 0 to 9. An impairment index (II) was also constructed from the SNQ and questions were asked about the same sites as above. The subjects were asked to report if those pains had caused any restrictions in their daily activities (at or outside home) during the last 6 months. The possible answers were 0 = no restrictions, and 1 = some restrictions. The range of the index was from 0 to 9. Disability measures. The Activities of Daily Living (ADL) index was a reduced version of the ADL index used by Alaranta [ 181. The items were the following: getting out of bed, washing, toenail care, putting on socks or tights, sitting for at least half an hour, and walking outdoors. The range of the total
Couple
therapy
in CLBP
patients
673
scores was from 0 to 12 points, in which 0 = no difficulties, 1 = some difficulties, 2 = no coping at all. The functional capacity index (FI) was based on patient self-reported assessment of functional capacity of his/her back at the time of the study: 1 = no difficulty with heavy workloads; 2 = difficulty only with heavy workloads; 3 = difficulty with moderate workloads; 4 = difficulties with light workloads; and 5 = continuous difficulty even at rest. Every alternative was illustrated with examples from everyday life. The range of the index was from 0 to 5. Clinical
examinations
The physiatrist’s examination (PE) included 12 functions: arm function; shoulder muscles; low back mobility; back muscles; gluteal muscles; leg muscles; hip and knee function as well as sitting, standing, undressing and walking. All functions were assessed as: 0 = normal; 1 = slight difficulty; 2 = moderate difficulty; 3 = severe difficulty. The scores of this index ranged from 0 to 3. The physiotherapist assessed pain and tenderness during the examination (PTE) of low back mobility (at discus levels L5-Th7). The following scores were used: 0 = no pain and tenderness; 1 = mild pain and tenderness; 2 = severe pain and tenderness. The range of the index was from 0 to 2. The same physiatrist and physiotherapist carried out examinations at the beginning and at the followup of the study. They were blind to the group assignment of the patients. Data nnaiy.sis The LISREL model [ 191, (Fig. 1) was used to analyze correlationicovariance groups at the beginning of the study and at the 12.month follow-up.
[
structures
Painindex
of the study
(es,
jlmpairmentindex+eZ
EXAMINATIONS
FIG. 1 shows
the LISREL-model,
e = measurement
error.
The model was intended to show relations between pain, disability and clinical measures at the beginning of the study and at the If-month follow-up study, as well as to describe the stability and reliability of the measures. The parameters of the model were estimated by the principle of the least squares, assuming that the qualities of each measure (e.g. reliability) remained unchanged during the one-year study period. Furthermore, the General Linear Model (GLM) of the SAS software system [201 was used for testing the mean effects of the treatment. Multivariate analysis of variance (MANOVA) for repeated measures was used for assessing changes in pain, disability and clinical measures. Univariate analysis of variance (ANOVA) was used to test the treatment effect on the use of medical services. A value of p < 0.05 was considered to be significant.
RESULTS
According to the LISREL model, reliabilities of the measures were the following: PI 0.81, II 0.89, ADL 0.76, FI 0.58, PE 0.79 and PTE 0.49.
S.
674
SAARUARW
Table I shows correlations between pain, beginning of the study and at the follow-up TABLE l.-CORRELATIONS Therapy
et al disability and clinical in both groups.
measures
at the
BETWEEN PAIN, DISABILITY AND CLINICAL. MEASURES
group:
P/l D/l C/l PI12 D/12 c/12
P/l 1.00 0.05 0.31 0.60 0.05 0.31
D/l
C/l
Pi12
D/l2
Cl12
I .oo 0.24 0.71 1.oo*
1 .oo 0.36 0.24
1.00 0.71
1 .oo
P/l 1.00 0.43 0.42 0.87 0.20 0.25
D/l
C/l
PI12
D/l2
c/12
I .oo 0.09 0.33 0.72 -0.08
1 .oo 0.37 0.17 0.82
1.00 0.42 0.53
1.00 0.18
I .OO
1 .oo 0.71 0.36 1 .oo* 0.71
* = fixed values Control P/l D/l Cl1 PI12 D/l2 Cl12
group:
P = pain measures. D = disability measures, C = clinical measures. The matrix shows correlation coefficients between the above measures and at the 12.month follow-up.
at the beginning
of the study
It is seen that correlation coefficients between pain, disability and clinical scores were high, indicating the stability of the measures in both groups during the study year. In the therapy group, correlation coefficients between initial and follow-up disability and clinical measures, respectively, became slightly greater than 1.OO. This indicates that one factor was not sufficient to explain the relation between the two measures. In other words, the residual variances included measurement-specific variation and measurement errors. Therefore, these correlation coefficients were fixed at 1 .OO in the final LISREL model, (see Table I). The goodness of the fit index of the model was then 0.98. The scattergrams for initial and follow-up measures of pain are plotted in Figs 2 and 3. 12 lo-
&
0
FIG. 2. Shows pain measures
2
in the therapy
4
6
6
group at the beginning follow-up ( = y).
10
12
of study ( = x) and at the 12.month
Couple
FIG. 3. Shows
pain measures
therapy
in CLBP
patients
in the control group at the beginning 12.month follow-up ( = y).
67.5
of the study
( = x) and at the
Pain measures were initially higher in the therapy group than in the control group (p = 0.04, MANOVA). No significant initial differences between the study groups were noted in disability and clinical measures. Outcome
effects
No significant gender differences were found in any of the measures used in the present study. No significant outcome effects (MANOVA) were observed in pain, disability or clinical measures during the study year (Table II). TABLE
II.-OUTCOME
Pre Mean (SD)
Post Mean (SD)
29 30
6.79 5.13
(2.64) (2.96)
5.93 4.87
(2.75) 2.76)
29 30
7.55 5.63
(2.57) (3.05)
6.62 5.27
(2.77) (2.97)
29 30
3.97 3.50
(2.06) (2.06)
4.10 3.83
(2.01) (2.00)
29 30
3.52 3.30
(1.09) (0.79)
3.52 3.13
(1.06) (0.90)
29 30
0.80 0.73
(0.32) (0.26)
0.59 0.55
(0.29) (0.24)
29 30
0.45 0.33
(0.45) (0.37)
0.59 0.34
(0.56) (0.33)
29 30
2.38 1.77
(2.97) (2.35)
2.21 1.03
(2.62) (1.30)
29 30
24.3 16.1
(35.8) (31.8)
20.3 19.3
(26.2) (49.8)
n
Pain index T-group c-group Impairment index T-group c-group ADL index T-group C-group Functional capacity index T-group C-group Physiatrist’s examination T-group c-group Physiotherapist’s examination T-group C-group Visits to physician T-group c-group Sick-leave days T-group c-group T = therapy
group,
C = control
MEASURES
group
676
The groups
S. SAARIJ~RVI et al.
did not differ (ANOVA)
in the use of medical
services
(Table
II).
DISCUSSION
To our knowledge, our study is the first randomized controlled study on the effectiveness of couple therapy in CLBP patients drawn from community health care centers. The poor validity and reliability of measures has been one serious obstacle in chronic pain treatment outcome studies. It is not always clear whether the changes reflected in the correlations are due to the treatment or simply artifacts due to pool stability or low reliability or a mixture of both during the course of the follow-up study. In this study efforts were made to overcome the common problems of statistical analysis in therapy studies. Most of the measures used in the study were found highly reliable and stable in statistical analysis. Disability was assessed in terms of pain and disability measures as well as results of clinical examinations and use of medical services. No significant changes were seen in single functional and mainly physical measures during the one-year study period either in the treatment or in the non-treatment control group. Only a slight decreasing tendency in pain complaints was noted in the treatment group. We recently showed that couple therapy improves marital communication of CLBP patients [lo] with a positive effect on social integration handicap (‘the individual’s ability to participate in and maintain customary social relationships’) [l 11 associated with chronic low back pain. We then assumed that the improved communication of CLBP patients could be reflected as a decrease in their pain complaints. This hypothesis was not confirmed by the present study conducted with the same couples. One possible explanation to negative findings might be the lack of severe marital problems [2 I I. In addition the previous Swedish Back School may have left little room for further improvement of the chronic pain. Me&analysis of non-medical treatments for chronic pain has shown that psychological therapies can relieve pain-related distress while the pain itself remains unchanged [221. Szasz suggested that chronic pain and especially complaints of pain may have a non-verbal communicative function which is impossible to express by other means [231. Our present empirical results support these two assumptions. The duration of follow-up may be critical for the interpretation of results. Many outcome studies of psychological therapies have been based on very short follow-up periods; usually only the immediate outcomes after the end of therapy have been reported. In this study the follow-up examinations took place six months after the couple therapy. The timing of follow-up assessments were chosen according to the recommendations of marital therapy and pain researchers [22, 24, 251. However, it is very difficult to conclude from previous empirical reports whether the therapy effect can be lost in one year or whether observation time of one year was too short to uncover changes in the disability of chronic pain patients. We assume that improved marital communication can relieve pain experience in due course. To test this hypothesis a five year follow-up study of these same CLBP patients is currently taking place. With the above reservations we conclude that, although couple therapy improves
Couple
therapy
in CLBP
patients
marital communication [ 101, it does not alter significantly disability in CLBP patients drawn from the community
617
self-reported and assessed health care centers.
Acknowledgements-We would like to thank Drs M.T. Hyypl and V. Lehtinen for their advice during the preparation of this paper. The study was supported by a grant from the Social Insurance Institution, Finland.
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