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5 June 2014
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Q1 Reply to Letter to the Editor
Dose or content? Effectiveness of pain rehabilitation programs for patients with chronic low back pain: A systematic review
We appreciate the opportunity to respond to the letter by 11 Nicholas A. Beckmann and Marcus Schiltenwolf  regarding our 12 systematic review, ‘‘Dose or content? Effectiveness of pain rehabil13 itation programs for patients with chronic low back pain: A 14 systemic review’’ . We want to thank the authors for sharing 15 their thoughts about dose in pain rehabilitation programs 16 (PRP).This will bring attention to the need for disentangling differ17 ent aspects of dose and content inﬂuencing the effects of PRPs. 18 The authors of this letter point out 2 essential topics to which 19 we want to reply. 20 First, the authors rightly pointed out that it is an assumption 21 that each hour of treatment (dose) is equivalent for each treatment 22 modality. This reinforces our point about the complexity of dose 23 and content factors inﬂuencing PRPs. 24 Second, we also agree with the authors that our review consists 25 of studies with heterogeneous groups of treatments, patient popu26 lations, follow-up times, outcomes and measurements per out27 come. In the absence of standardized outcome measurements, 28 we categorized the measurements related to disability, work par29 ticipation, and quality of life. However, in this systematic review, 30 we reported data and outcomes of a heterogeneous source of stud31 ies in the literature. Factors such as patient compliance and moti32 vation are known to affect outcome [2,3]. However, data regarding 33 Q2 these factors are rarely reported in RCTs in general, and were not 34 reported in our source literature; therefore, we could not report 35 on these and other relevant issues. 36 Q3 As we described, in the Discussion section of our review, it is 37 difﬁcult to disentangle dose and content aspects of PRPs; but, from 38 our point of view, it is very important to include all aspects of a 39 study in order to analyze the effects of PRPs. We agree with 40 Williams  that our review has laid some groundwork for further 10
research to disentangle dose and content factors in PRPs so as to improve these programs. Finally, we disagree with Beckmann and Schiltenwolf that discussing dose of treatment appears to be premature. Our review has demonstrated that dose issues have been neglected in PRP research, and we believe that studying dose in PRPs is necessary and long overdue.
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Franka P.C. Waterschoot Q5 Pieter U. Dijkstra Jan H.B. Geertzen Michiel F. Reneman Department of Rehabilitation Medicine, Center for Rehabilitation, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands Q6 ⇑ Corresponding author. Q7 E-mail address: [email protected]
Pieter U. Dijkstra Department of Oral and Maxillofacial Surgery, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands Q8
 Beckmann NA, Schiltenwolf M. Letter to the editor. PAINÒ 2014.  Hildebrandt J, Pﬁngsten M, Saur P, Jansen J. Prediction of success from a multidisciplinary treatment program for chronic low back pain. Spine (Phila Pa 1976) 1997;22:990–1001.  Kerns RD, Rosenberg R. Predicting responses to self-management treatments for chronic pain: application of the pain stages of change model. PAINÒ 2000;84:49–55.  Waterschoot FP, Dijkstra PU, Hollak N, de Vries HJ, Geertzen JH, Reneman MF. Dose or content? Effectiveness of pain rehabilitation programs for patients with chronic low back pain: a systematic review. PAINÒ 2014;155:179–89.  Williams AC. How do we understand dose of rehabilitative treatment? PAINÒ 2014;155:8–9.
http://dx.doi.org/10.1016/j.pain.2014.05.017 0304-3959/Ó 2014 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved.
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