Interdisciplinary Multimodal Pain Therapy for chronic musculoskeletal pain in a day clinic setting: Examining patient-reported and performance-based correlates of treatment outcomes

Interdisciplinary Multimodal Pain Therapy for chronic musculoskeletal pain in a day clinic setting: Examining patient-reported and performance-based correlates of treatment outcomes | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Interdisciplinary Multimodal Pain Therapy for chronic musculoskeletal pain in a day clinic setting: Examining patient-reported and performance-based correlates of treatment outcomes Jana Maas, Stephan Vinzelberg, Karolina Kolodziejczak-Krupp, Lea Wilhelm, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6865142/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Objectives The aim of this single-arm pre-post intervention study was to evaluate an interdisciplinary multimodal pain therapy (IMPT) in a day clinic for people with chronic musculoskeletal pain under routine care conditions. Primary objectives included assessing changes in pain intensity and pain-related disability and examining theory- and evidence-based correlates of these treatment outcomes, such as parameters of mental and physical health. Methods A cohort of n = 308 patients underwent a four-week IMPT, which included exercise, manual therapy, and cognitive behavioural therapy. Pain intensity and disability (CPG), well-being (FW-7), mental and physical health (VR-12), depressive symptoms, anxiety, and stress (DASS) were assessed using self-report questionnaires before and six months after the IMPT was completed. Physical function was assessed using performance-based measures including the stair climb test, the MFT-S3-Check and the prone bridge test before and after treatment. Data were analysed using dependent samples t -tests and multiple linear regressions. Results Six months post-treatment, patients showed reductions in pain intensity ( d = .95) and disability ( d = .75). Reductions in depression, anxiety, and stress,well-being, mental and physical health, and physical function were also observed, with small to large effect sizes. Regression analysis showed that improvements in self-reported well-being and physical health were associated with changes in pain. However, this was not the case for changes in performance-based physical function or changes psychological risk factors (i.e., depressive symptoms, anxiety, stress). Discussion The results indicate that individuals with chronic pain experienced sustained benefits from IMPT for up to six months following treatment completon. The findings highlight the role of changes in self-reported well-being and physical health in reducing pain. The investigation of psychosocial and behavioural mechanisms is an important avenue for future studies. interdisciplinary multimodal pain therapy chronic pain physical function well-being physical health Figures Figure 1 Figure 2 Introduction The long-term effectiveness of interdisciplinary multimodal pain therapy (IMPT) in treating chronic pain has been demonstrated repeatedly 1 , 2 . IMPT is a complex intervention incorporating different treatment components provided by a multidsiciplinary team 3 and has been shown to lead to reductions in pain, improvements in functional ability, a faster return to work, and appears to be cost-effective 1 , 4 – 7 . The primary treatment outcomes of IMPT usually include self-reported, pain-related outcomes. However, to optimise IMPT, evaluations need to consider not only whether individuals benefit from the intervention (e.i. is the intervention effective?), but also why they benefit from it. The first step in answering the latter question is to a) assess potential mediators of treatment effects and b) analyse whether changes in these mediators are associated with changes in treatment outcomes (i.e. pain intensity, pain-related disability). Prior research has indicated that patients with high pain intensity levels benefit from IMPT 8 , 9 . Furthermore, sociodemographic factors such as gender, age, and work status have been shown to correlate with treatment outcomes. For example being younger 10 , being male 9 , and having a shorter duration of sick leave 11 , 12 were associated with greater improvements in pain. With regard to psychological variables, changes in pain intensity measures after IMPT have been shown to correlate with improvements in risk factors, such as depression and catastrophizing 13 and to be associated with positive treatment expectations 13 and higher acceptance of one’s condition 14 . Daenen et al. 15 describe exercise therapy as a fundamental part of the conservative treatment of chronic musculoskeletal pain and most IMPTs also specifically aim to improve patients' physical functioning in order to reduce pain 16 . Guidelines for managing chronic pain recommend exercise as an important treatment modality 17 and performance-based measured of physical function have been shown to improve following IMPT 18 , 19 . However, previous research into the relationship between pain-related treatment outcomes and performance-based measures of physical function, has produced incosistent results. While some studies have shown that changes in physical function, such as strength and endurance, correlate with changes in pain following treatment 20 , other studies have shown that performance-based measures of physical function are unrelated to improvements in pain intensity and disability 21 . This study therefore uses routine care data from an established IMST in a day clinic setting to a) evaluate the IMPT in terms of pain-related primary treatment outcomes (i.e. pain intensity, pain-related disability), b) evaluate the IMPT in terms of potential patient-reported and performance-based mediators of treatment effects, and c) examine the extent to which patient-reported and performance-based variables are associated with changes in pain-related treatment outcomes. It was hypothesised that reductions in pain intensity and pain-related disability, as well as improvements in self-reported measures of mental and physical health, would be observed six months after the IMPT program.We also hypothesized that there would be an improvement in objective, performance-based measures of physical function following IMPT. Secondly, we hypothesized that both changes in mental and physical health, as well as parameters of physical function would be associated with changes in pain intensity and pain-related disability. Materials and Methods Ethical approval, trial registration The Ethics Committee of the MSB Medical School Berlin approved the study on 05/05/2025 (approval number MSB-2025/246). The study was registered retrospectively in the German Clinical Trials Register (DRKS00036855), which is also available on the International Clinical Trials Registry Platform. Participants and procedure The present study is a single-arm pre-post intervention study. Participants were patients at a day clinic for manual medicine at the Sana Hospital Lichtenberg between November 2019 to August 2022. To be eligible for the IMPT program, patients had to have experienced chronic pain (at least three months) in the musculoskeletal system. This could include conditions such as back pain, joint pain, and headaches. The aetiology of the pain had to be multifactorial, involving a combination of complex functional musculoskeletal findings, pathomorphological changes, and psychosocial factors. Further details on the inclusion and exclusion criteria can be found in the supplementary material S1. Eligibility for the IMPT programme was assessed during an outpatient diagnostic appointment, consisting of one-hour medical and psychological examinations. This included an evaluation of the patient's pain characteristics, physical function and psychosocial health. Between November 2019 and August 2022, 422 patients attended the diagnostic assessment, and 308 of these received a recommendation for IMPT at the day clinic. The remaining 114 patients were advised to pursue alternative treatment, such as inpatient IMPT or psychosomatic treatment. On average, patients had to wait two months after the diagnostic assessment before starting IMPT. All participants gave written informed consent for their data to be used to assess treatment quality. As part of this evaluation participants completed paper-pencil questionnaires at the time of their diagnostic appointment (T0), underwent physical performance tests to measure physical function at the start (T1) and end (T2) of IMPT, and were reassessed with questionnaires six months after treatment (T3). The study design is shown in Fig. 1 . Interdisciplinary multimodal pain therapy (IMPT) The patients were enrolled in an IMPT program, which was provided by a team of healthcare professionals with expertise in the treatment of pain. This complex treatment is understood as a conservative orthopaedic pain therapy approach that incorporates manual medicine-oriented diagnostics and therapy, physical training and cognitive behavioral psychotherapy. The program aims to restore and improve physical functioning and reduce pain-related disability and pain intensity. Patients participate in a four-week therapy program comprising 100 hours in total. The treatment plan was standardized for all patients and included strength training, endurance training, relaxation training and medical and psychological education on pain and pain management, among other things. An example of a weekly schedule can be found in the supplementary material 2. In addition to the group program (closed groups of up to eight), patients had weekly individual sessions with their reference therapists (physician, physiotherapist/sports therapist, psychologist). A daily one-hour team meeting was held to facilitate interdisciplinary communication between team members. A more detailed description of the IMPT, following the TIDieR-Rehab checklist (Signal et al., 2024), can be found in the supplementary material (see S1). Coding intervention content in pain therapy in behaviour change techniques As previous research has often lacked clarity regarding the exact implementation of the IMPT 22 , the IMPT content was coded post-hoc using a German version of the standard behaviour change taxonomy 23 , 24 . The purpose of the coding was to make IMPT more replicable and comparable. This taxonomy aims to systematically and reliably identify the content of behaviour change interventions using a list of 93 different behaviour change techniques (BCTs 23 ). BCT refers to a measurable and irreducible element of an intervention that is designed to modify or influence the underlying processes regulating behavior 25 . Treatment content was categorized into BCTs independently by two raters (JM, LF), then compared and adjusted in a consensus process. An overview of the BCTs used in the treatment is provided in Table 1 . Table 1 Content, form of delivery and behavior change techniques (BCTs) of the intervention Content Method Profession Organization / Setting Material BCT Target behavior Aim of the intervention component Definition of individual behavioral goals (incl. context, frequency, duration and/ or intensity) Frontal teaching, group discussion, one-on-one Physicians, psychologists, physiotherapists, sports therapists Conference room, treatment room Presentation, writing material, printed individualized instructions Action planning (1.4), goal setting (behavior) (1.1) Physical activity, nutrition, relaxation, sleep Facilitate behavior change Analysis of barriers for behavior change & development of strategies to overcome those Frontal teaching, group discussion, one-on-one Psychologists, physicians, physiotherapists, sports therapists Conference room, treatment room Presentation Problem solving (1.2), social support (practical) (3.2), social support (emotional) (3.3) Physical activity, sleep, relaxation, nutrition, stress management Facilitate behavior change Feedback on change in physical performance One-on-one Physicians, physiotherapists, sports therapists Treatment room Visual presentation of outcome Feedback on outcomes of behavior (2.7) Physical activity Help patients build motivation Exploration of perceived causes of behavior & development of an explanatory model Frontal teaching, group discussion, one-on-one, physician’s round Physicians, psychologists, physiotherapists, sports therapists Conference room, treatment room Presentation, writing material, flipchart Re-attribution (4.3) Adaptive Coping (instead of catastrophizing) Reduce insecurity and increase self-efficacy for suitable behavior in patients Information on consequences of a variety of behaviors on physical & mental health & emotional well-being Frontal teaching, group discussion, one-on-one, physician’s round Physicians, psychologists, physiotherapists, sports therapists Conference room, treatment room Presentation, flipchart, work sheets Information about health consequences (5.1), emotional consequences (5.6), credible source (9.1) Physical activity, sleep, relaxation, nutrition, stress management Increase self-responsibility and motivation to implement health behavior Instruction, demonstration and instigation of rehearsal of behavior Frontal teaching, modeling, one-on-one Physicians, psychologists, physiotherapists, sports therapists Conference room, treatment room, training room, outside Presentation, video recordings Instruction on how to perform behavior (4.1), demonstration of the behavior (6.1), behavioral practice / rehearsal (8.1), credible source (9.1) habit formation (8.3), habit reversal (8.4), generalization of a target behavior (8.6), graded tasks (8.7) Physical activity, sleep, relaxation, nutrition, stress management, communication and decision-making skills Improve patients’ well-being and self-efficacy, reduce pain Encouragement of adherence to the use of drugs if necessary Frontal teaching, one-on-one, physician’s round Physicians psychologists Conference room, treatment room Presentation Credible source (9.1), pharmacological support (11.1) Use of medication Improve patients’ well-being, reduce pain Working out ways to reduce unpleasant feelings Frontal teaching, group discussion, one-on-one Psychologists Conference room, treatment room Presentation, flipchart, work sheets Reduce negative emotions (11.2) Emotion regulation Improve patients’ well-being, reduce anxiety and stress Working out ways to redirect attention from unwanted bodily sensations Frontal teaching, group discussion, one-on-one Psychologists Conference room, treatment room Presentation Distraction (12.4) Adaptive coping with pain Reduce anxiety and pain intensity, increase self-efficacy Training, manual therapy, assistive aids (e.g. lumbar support), passive treatment methods (e.g. taping) Frontal teaching, modeling, one-on-one Physicians, psychologists, physiotherapists, sports therapists Treatment room, training room, outside Written instructions, audio- and video recordings Feedback on behavior (2.2), body changes (12.6) Physical activity and relaxation Improve patients’ well-being and self-efficacy, reduce pain Cognitive (re-) structuring (e.g. change of view on disability) Frontal teaching, group discussion, one-on-one Psychologists Conference room, treatment room work sheets Framing / Reframing (13.2), behavioral experiments (4.4), monitoring of emotional consequences (5.4), exposure (7.7), incompatible beliefs (13.3) Adaptive Coping (instead of catastrophizing) Reduce anxiety and pain intensity, increase self-efficacy Motivation and support of self-esteem Frontal teaching, group discussion, one-on-one Physicians, psychologists, physiotherapists, sports therapists Conference room, treatment room, training room, outside Presentation Verbal persuasion about capability (15.1), mental rehearsal of successful performance (15.2), focus on past success (15.3), self-talk (15.4) Physical activity, sleep, relaxation, nutrition, stress management Help patients build motivation and self-efficacy Italics: This BCT, content or material is included in the treatment if necessary. Self-report treatment outcomes At baseline (T0), demographic data were collected and patients were asked about the duration of their pain. Answers were given on a 6-point response scale (1 = 5 years) . At follow-up assessment (T3), patients were asked to rate the perceived success of the treatment on a 6-point scale (1 = very good , 2 = good , 3 = satisfactory , 4 = adequate , 5 = inadequate , 6 = insufficient ). The “pain questionnaire” of the German Pain Society, which encompasses several of the following measures, was used to collect data 26 . Primary outcome measure: pain intensity and pain-related disability The degree of pain intensity and pain-related disability were assessed using the validated German version of the Chronic Pain Grade questionnaire (CPG 27 , 28 ). Patients were asked to rate their pain intensity (current pain intensity; maximum and average pain intensity within the past four weeks) and their pain-related disability within the past three months (with regard to daily activities, leisure activities, and ability to work) using six 11-point numeric rating scales. The response scales ranged from 0 ( no pain/no impairment) to 10 ( most severe pain/no activity possible ). An additional item asked about the number of days in the past three months (six months in the original publication) during which the patient was unable to perform usual activities due to pain. The primary outcome variables were pain intensity (i.e., mean of current, average and maximum pain intensity multiplied by 10; ranging 0-100) and pain-related disability (i.e., mean of impairment in daily activities, leisure activities and ability to work multiplied by ten; ranging 0-100). The CPG allows the consctruction of a total score for grading the pain severity (i.e., Pain Severity Grade; four-step grading of pain intensity and disability; ranging 0–3). As it is often used to guide the selection of pain treatments and could provide an assessment of qualitative change, changes in pain severity grade were also evaluated. The German version has been shown to be reliable and valid 28 , although only the Brazilian Portuguese translation of the questionnaire has been tested for test-retest reliability, demonstrating moderate agreement²⁹. Physical and mental health Self-reported physical and mental health were measured using the German version of the Veterans RAND 12-Item Health Survey (VR-12 30,31 ). The response format of this instrument alternates between three (1 = yes, limited a lot to 3 = no, not limited at all ), five (1 = never to 5 = always or 1 = excellent to 5 = poor ) and six (1 = always to 6 = n ever ) response options. The items are divided into two component scores: physical and mental health. All 12 items are included in the calculation of each subscale and weighted according to their relevance to its content. Higher subscores indicate a more positive self-assessment of health. The VR-2 has been validated with patients with chronic pain 31 . Well-being The Marburg Questionnaire on Habitual Well-being (FW-7 32 ) was used to measure general well-being as a unidimensional factor. Respondents were asked to rate their level of satisfaction with their everyday and job performance despite their pain on a scale of 0 to 5, with 0 indicating strong disagreement and 5 indicating strong agreement. They were also asked to rate their level of comfort in various situations. Higher FW-7 total scores indicate higher levels of well-being. Basler 32 reports high internal consistency, test-retest reliability, and external validity with measures of pain chronification. Depressive symptoms, anxiety, and stress The short version of the Depression Anxiety Stress Scale (DASS) was used as a screening instrument to measure the subscales of depression, anxiety and stress, each with seven items (German version: Nilges & Essau³³). Items were rated on a 4-point scale (0 = did not apply to me at all to 3 = applied to me very much or most of the time ). Cut-off values of ≥ 10 for depression, ≥ 6 for anxiety, and ≥ 10 for stress indicate an increased likelihood for the respective psychological condition. The internal consistency and construct validity of the depression and anxiety subscales were good in the study conducted by Nilges and Essau 33 . Performance-based measures of physical function Balance and body stability The stability, sensorimotor regulation and symmetry test from Multifunktionale Trainingsgeräte GmbH (MFT-S3-Check 34 ; MFT Bodyteamwork GmbH, Vienna, Austria) was used. The measurement device consisted of a uniaxially mounted, unstable standing plate with an integrated sensor-controlled transducer and associated evaluation software. Participants were tasked with keeping the platform horizontal for 30 seconds. Normative values are available for men and women in different age groups so that the results of the test can be classified within a standardized reference system.The stability index can range from 1 ( very good ) to 9 ( very poor ). Scores below 5 are considered below average compared to the normative sample for all age groups. Raschner et al. 34 report high test-retest reliability and objectivity for the stability index. Physical fitness For the stair climb test (SCT), which assesses physical fitness, patients were asked to climb the stairs to the fourth floor as quickly as possible 35 . The time taken to climb the stairs was measured by physiotherapists or sports therapists using a stopwatch. The number of steps was based on local conditions (72 steps), so no comparisons can be made with other populations. Test-retest reliability was high in previous studies and there is evidence of good construct and criterion validity 36 . Trunk muscle endurance The prone bridge test was used to assess trunk muscle endurance 37 . Patients were positioned in a prone position with their elbows flexed at 90°, their legs extended, and their whole body aligned. They were then asked to lift their body off the floor (except for the arms and feet) and to hold this position for as long as possible. The test ended when the position was disturbed or the patient fell. The duration was recorded in seconds. This test has been shown to validly measure trunk muscle endurance, with high test-retest reliability 38 , 39 . Statistical analysis The mean and standard deviation of all variables were calculated, with the significance level set at alpha = .05 for each statistical analysis. Listwise deletion was used to adress missing data. For the dropout analyses, t-tests were used for interval-scaled variables and chi-squared tests were used for non-interval-scaled variables to compare values between participants who took part in the follow-up survey and those who did not. Changes in the self-reported measures of pain intensity and pain-related disability, well-being, physical and mental health, depression, anxiety and stress were evaluated by comparing baseline (T0) and follow-up (T3) measures using a series of dependent samples t-tests. Treatment outcomes for physical function (balance and stability, physical fitness and trunk muscle endurance) were assessed by comparing test scores at the beginning (T1) and end (T2) of the intervention. The subgroup of participants who took part in the physical performance tests at T1 and T2 was larger than the group who also completed the questionnaire at T3. This is why the sample size differs in these analyses. Effect sizes were calculated using Cohen's d and interpreted as small (.2), medium (.5) or large (.8) 40 . Pearson correlation coefficients were used to assess the correlation between the primary outcome measures, and the other factors at the different time points. The results were then used to select the variables for the regression analysis. Hierarchical linear regressions were performed to examine the extent to which changes in well-being, physical health, depression, stress, and physical function were associated with changes in pain intensity and pain-related disability at follow-up (T3). As previous studies have found correlations between pain duration, gender, age, and work status and treatment outcomes, these were included as control variables in the analyses. There was no difference in the results when 'pain duration' was included as either dummy variables (with five dummy variables representing the six categories, with '>5 years' as the reference category, as this category occurred most frequently) or as a pseudo-metric variable. Therefore, we included it in the final model as a pseudo-metric variable.An additional outcome variable was calculated based on the pain severity grade. By comparing pain severity grades at T0 and T3, a dichotomous variable was created to indicate whether there had been “improvement by at least one grade” (= 1) or “no change/worsened” (= reference category). Binary logistic regression was used to examine the extend to which well-being, physical health, depression, stress, and physical function were associated with pain grade progression vs. pain grade maintenance/regression. Complete case analysis was used. All analyses were performed using SPSS (version 28). Results Descriptive analyses Of the 308 patients who started treatment, seven (2.3%) discontinued it. In six cases, this was due to the onset of another illness (e.g., Covid infection) which prevented participation. In one case, it was due to an increase in depressive symptomss following the abrupt cessation of antidepressant medication shortly before the start of treatment. Patients had various and sometimes multiple diagnoses with lumboischialgia (25.5%), chronic pain disorder with somatic and psychological factors (17.8%), low back pain (12.5%), and cervicobrachial syndrome (11.2%) being the most common. As shown in the flowchart (Fig. 2 ), the follow-up survey six months after the end of treatment (T3) was completed by 137 participants (44.5%).There was no significant difference in most variables between participants who completed only the initial questionnaire (= drop-out participants) and those who completed both the initial and follow-up questionnaire (= completers). However, completers had lower mean scores on the anxiety subscale of the DASS at baseline ( M = 3.20) compared to drop-out participants (M = 4.20), t (290) = 2.39, p = .017, d = .28. In the drop-out group, fewer participants were working compared to the completers, χ ²(1, N = 290) = 4.15, p = .042. The following descriptive data refer to participants who completed the questionnaires both at T0 and T3 ( n = 137). However, completers had lower mean anxiety subscale scroes on the DASS at baseline ( M = 3.20) than drop-out participants (M = 4.20), t (290) = 2.39, p = .017, d = .28. Fewer participants in the drop-out groupwere working compared to the completers, χ ²(1, N = 290) = 4.15, p = .042. The following descriptive data refer to participants who completed the questionnaires at both T0 and T3 ( n = 137). The mean age of the participants was 50 ± 11 years and 69% ( n = 95) were women. At baseline (T0), 62% ( n = 75) of participants were working. The remaining participants were either on sick leave, retired, unemployed, or in education. The mean body mass index (BMI) was 25.96 ± 4.83 kg/m 2 . At baseline (T0), 43 participants (34%) categorized the duration of their pain as > 5 years, 24 (19%) as 2–5 years, 22 (18%) as 1–2 years and 36 (29%) as 6 months − 1 year. The mean current pain intensity as measured by the first item of the CPG, was 5.74 ± 1.72 (0–10). At follow-up (T3) participants rated the program as follows: very good (32%), good (29%), satisfactory (20%), adequate (11%), inadequate (8%) and insufficient (0%). Correlations between the primary outcome measures, and the other factors at the different time points can be seen in Table 2 . Content of the intervention Table 1 summarizes how the intervention content aligned with the identified BCTs. Of the 93 BCTs, 27 techniques were identified within the intervention at least once. The majority of the identified BCTs belonged to the clusters repetition and substitution ( n = 5), self-belief ( n = 4), goals and planning ( n = 3), and shaping knowledge ( n = 3; see Table 1 ). Changes in the variables across time Table 3 shows changes in pain intensity, pain-related disability, well-being, physical and mental health, depression, anxiety, stress between baseline (T0) and follow-up (T3). Significant changes in the hypothesized direction were observed for all variables, with effect sizes ranging from small ( d =-.24 for mental health and d = .25 for anxiety)) to large ( d = .90 for physical health, d = .95 for pain intensity). Table 3 also shows a comparison of physical function parameters at the start (T1) and end (T2) of treatment. Significant improvements were observed in all three measures, with the largest effect size (-1.12) seen in the change in trunk muscle endurance. Examining the distribution of CPG pain severity grades at baseline (T0) and follow-up (T3), it was found that 77 participants (65%) improved by at least one grade, 30 participants (25%) experienced no change, and 12 participants (10%) reported an increase in pain severity by at least one grade (see Table 4 ). Table 3 Change in the variables over time Questionnaire T0 T3 M SD M SD t df p Cohen’s d Pain intensity (CPG) 62.24 15.41 40.05 24.21 10.39 118 < .001 .95 Pain-related disability (CPG) 54.80 23.15 31.65 25.38 8.19 117 < .001 .75 Physical health (VR-12) 33.31 9.63 43.53 10.78 -9.64 115 < .001 − .90 Mental health (VR-12) 35.48 6.54 37.54 6.85 - 2.57 115 .006 − .24 Well-being (FW-7) 14.23 7.74 21.47 8.42 -8.30 121 < .001 − .75 Depression (DASS) 6.68 4.63 4.26 4.28 6.25 119 < .001 .57 Anxiety (DASS) 3.10 3.09 2.44 3.00 2.70 119 .004 .25 Stress (DASS) 8.48 4.95 6.19 4.74 5.39 119 < .001 .49 Physical performance tests T1 T2 M SD M SD t df p Cohen’s d Balance & Stability (MFT-S3-Check) 5.37 1.02 5.05 1.06 7.06 256 < .001 .44 Physical fitness (SCT) 40 15.70 35.45 13.27 9.80 251 < .001 .62 Trunk muscle endurance (prone bridge test) 37.76 21.86 65.84 29.80 -16.89 224 < .001 -1.12 Note: CPG indicates Chronic Pain Grade; VR-12, Veterans RAND 12-Item Health Survey; FW-7, Marburg Questionnaire on Habitual Well-being; DASS, Depression Anxiety Stress Scale; SCT, stair climb test; 116 ≤ n ≤ 257 due to missing values. Table 4 Number of patients per pain severity grades based on von Korff28 at T1 and T3 Pain severity grade (T3) Total I II III IV Pain severity grade (T0) I low intensity & low disability 9 3 0 0 12 II high intensity & low disability 29 12 0 7 48 III high disability & moderately limiting 11 6 1 2 20 IV high disability & severely limiting 18 10 3 8 39 Total 67 31 4 17 119 Note. Grey background indicates improvement. Correlates of changes in pain intensity and pain-related disability Multiple regression analysis was used to test for significant associations between changes in self-reported psychological and performance-based physical parameters and changes in participants' pain intensity.. The results of the regression analysis, which controlled for pain duration, gender, age and work status, are shown in Table 5 . These results indicate that two variables explained 44.1% of the variance, F (6,96) = 12.60, p < .001. Specifically,changes in both self-reported physical health (VR-12) and change in well-being (FW7) were significantly associated with changes in pain intensity (B = 1.11, p < .001, and B = 0.73, p < .001, respectively). Table 5 also shows the results of the regression analysis in which change in reported pain-related disability was used as the dependent variable. Consistent with previous pattern, changes in physical health (B = 1.65, p < .001) and change in well-being (B = 1.48, p < .001) were significantly associated with changes in pain-related disability. Changes in depressive symptoms, stress and in the physical function parameters were not significantly related to the changes in pain intensity or pain-related disability. Table 5 Prediction of change in pain intensity Change in pain intensity Change in pain-related disability Predictors B SE R R 2 ΔR² B SE R R 2 ΔR² Step 1: .27 .07 .03 .28 .08 .65 Duration -3.84 1.65 -5.96 2.17 Age .18 .21 .05 .27 Gender − .69 4.90 -2.96 6.11 Work-status -8.08 4.93 2.13 6.47 Step 2: .61 .37*** .33 .67 .45*** .42 Change in physical health 1.11 .17 1.65 .20 Step 3: .66 .44*** .41 .79 .63*** .60 Change in well-being .73 .21 1.48 .22 Step 4: .66 .44 .39 .79 .63 .60 Change in depression .05 .57 .59 .61 Change in stress − .11 .49 − .44 .53 Step 5: .67 .46 .39 .79 .63 .59 Change in balance and body stability 2.52 2.47 -1.01 2.70 Change in physical fitness .31 .09 .17 .31 Change in trunk muscle endurance .04 .08 − .05 .09 * p < .05 ** p < .01 *** p < .001; N = 108 Logistic regression was used to analyse the association between changes in psychological and physical parameters and the likelihood of an improvement of at least one pain grade on the CPG (reference category 0 = “no change / worsened”). Together, the variables accounted for a significant amount of variance in the outcome; the likelihood ratio test comparing a full model with a reduced model resulted in a chi-squared value of 50.25, with a p-value of less than .001. Again, only change in physical health, OR = 1.11 95% CI [1.03, 1.19], p = .006, and change in well-being OR = 1.13, 95% CI [1.04, 1.23], p = .003, were independently associated with changes in the graduation of pain. The odds of a reduction in the CPG by at least one grade, compared to no change or worsening, increased by 11% for each one-point increase in self-reported physical health and by 13% for each one-point increase in self-reported well-being, when holding the other variables constant. Discussion The overall aim of the present pre-post analysis was to evaluate an IMPT for individuals with chronic musculoskeletal pain in the context of routine day clinic care. This evaluation considered changes in patient-reported variables and performance-based measures (e.g., prone bridge test, SCT, MFT-S3-Check) after the intervention. As well as analysing changes in the primary treatment outcomes (i.e., pain intensity, pain-related disability), the study examined changes in potential mediators of the treatment effects, and their associations with the pain-related outcomes. Six months after treatment, reductions in pain intensity (CPG) and pain-related disability (CPG) were observed, with large and medium effect sizes, respectively.These findings align with previous research demonstrating the effectiveness of IMPT in reducing musculoskeletal pain 1 , 41 – 45 , further supporting its robustness as a therapeutic intervention for chronic pain. Regarding potential mediators, self-reported measures showed improvements in physical health (VR-12) with a large effect size, reductions in depressive symptoms (DASS) and improvements in general well-being (FW-7) with medium effect sizes, and reductions in stress, anxiety (DASS) and mental health (VR-12) with small effect sizes. Furthermore, performance-based measures showed improvements from the start to the end of treatment, with small to large effect sizes, suggesting that IMPT is associated with objectively measurable changes in physical function. Few participants (2.3%) dropped out of the treatment program, and satisfaction with the treatment remained high. In terms of intervention content, healthcare professionals in the interdisciplinary treatment team most frequently used BCTs that focused on coping strategies (e.g., reattribution), advising patients on how to perform recommended health behaviours correctly (e.g., behavioural rehearsal of specific exercises), and motivating patients to engage in specific health behaviours (e.g., behavioural instruction, verbal persuasion of ability). BCTs that empower patients to regulate their own health behaviours in daily life (e.g., habit formation, action planning) were used less frequently, but would be a valuable addition to current IMPT programmes in order to support the sustainability of treatment effects. Rather than objective measures of physical function, changes in self-reported well-being and physical health were associated with changes in pain intensity, pain-related disability and pain grade classification. Contrary to other studies 9 , 10 , 11 , 12 , age was not associated with a reduction in pain intensity or disability and neither was pain duration, gender or work status. It is possible that there are bidirectional relationships between well-being, physical health and pain. For example, pain could negatively impact subjective health and well-being. A large study by Ritchie et al 46 found that persistent pain in older adults was associated with a decline in self-reported physical function and well-being over a seven years. However, a review examining prognostic factors for self-reported physical functioning (as measured by the VR-12) after an IMPT found that pain intensity was unrelated to physical functioning 47 . Karayannis et al. 48 used a parallel process latent growth curve modelling to study the relationship between pain interference and self-reported physical functioning. They found a weak one-way relationship between physical functioning and pain interference over 90 days. This suggests that changes in physical functioning are associated with changes in pain interference, rather than the other way around. Future studies should further examine whether improvements in self-reported parameters of physical health lead to pain reduction via specific pathways, such as increased mobility,enhanced mental health or improved well-being. Contrary to our hypotheses, changes in objective physical function parameters were not associated with improvements in pain intensity and disability. This is consistent with previous studies, in which pain correlated with self-reported disability, rather than performance-based measures 49 , and in which physical variables showed little prognostic value for outcome parameters 19 , 50 – 52 . In contrast to our hypotheses and unlike previous studies, where reductions in depressive symptoms coincided with reductions in pain⁵³ , ⁵⁴reductions in anxiety, depressive symptoms and stress did not correspond with pain reductions. Additionally, the effect size for changes in mental health and anxiety at follow-up compared to baseline scores was smaller than for the other variables. These differing results may be due to differences in the study population, methodology or types of intervention used. This suggests that the relationship between mental health and pain may not be universal across all contexts.The mean scores for depression, anxiety and stress (DASS) by the sample in this study were lower than in a population with chronic low back pain using the same questionnaire 55 , which limits the potential for improvement after the intervention. Compared to other multimodal outpatient treatment programs this treatment was relatively short but intensive 56 . In a systematic review, Scascighini et al. 56 did, however, not find a significant relationship between the treatment duration and success. Present findings should be replicated using additional patient-reported measures to assess depressive symptoms, as recent studies have suggested that the psychometric properties of the DASS may be limited. 57 . When comparing the questionnaires used in this study to assess different aspects of mental health (DASS, VR-12, FW-7), the DASS and VR-12 are more deficit-oriented than the FW-7. This distinction is particularly relevant given that one of the stigmas feared by people with chronic pain is psychologisation 58 , which may lead to a reluctance to respond positively to items that address mental health problems specifically. At a content level, the associations between changes in well-being (FW-7) and changes in pain intensity and pain-related disability found in this study, may also support a greater focus on potential protective resources that help individuals to become and /or remain healthy 58 , 59 , 60 . As well as targeting mental health outcomes such as depression, IMPT should specifically target resources and theory-based, psychological risk factors of pain chronification 61 , 62 . At the behavioural level, researchers may also consider measuring the extent to which individuals adhere to health behaviours relevant to pain management (e.g. physical activity, relaxation techniques). As such, IMPT can be understood as a multiple behaviour intervention 63 and it is likely that multiple behaviour changes contribute to treatment success. Factors that potentially contribute to this but were not assessed in this study include catastrophizing, fear-avoidance behaviour, self-efficacy, expectations, and perceived social support 13 , 64 – 66 . In a study done by Furrer et al. 67 , pain catastrophizing mediated the effect of subjective well-being on pain intensity and pain interference. Optimism is one of factor that has been shown to be associated with self-reported physical functioning 68 . Exercise training and subsequent improvements in physical function may influence pain intensity and disability through changes in pain processing, self-efficacy, motivation and mood 21 . The study design of the present study has some limitations. The data of the current study were collected in a naturalistic setting of a day clinic. A major limitation of this study is the lack of randomized control groups (e.g. alternative pain treatment or no intervention). Additionally, there was an asymmetric timing of the assessments: unlike the physical performance tests, the questionnaire data were collected at the six-month follow-up, rather than post-treatment due to clinic logistics. So while the external validity of our results is high, we cannot make any causal inferences about the observed changes following the treatment. The response rate to the follow-up survey was low, and those who participated in the follow-up survey differed from those who dropped out in terms of anxiety levels and work status. This leaves room for non-response bias and limits generalizability. The initial questionnaire survey was conducted approximately two months prior to the start of IMPT, during which time symptoms may have changed, for example, due to expectations of treatment 69 . In other studies, a decrease in pain and passive pain coping strategies was observed during the waiting period 70 , 71 . As the patient group was diverse, with pain in various musculoskeletal areas, results may vary by subgroup andthe standardized nature of the program may not fully address patients’ diverse needs. Future evaluations should include longer follow-up periods to examine IMPT sustainability and assess patient adherence, since long-term adherence to exercise programs has been demonstrated to be challenging for patients 16 . In conclusion, the results of this study suggest that individuals with chronic musculoskeletal pain can benefit from IMPT in routine caresettings. This improvement was evident in both pain-specific outcomes (i.e. pain intensity and disability) and physical function, well-being, and mental and physical health. However, it was changes in self-reported well-being and physical health rather than in performance-based measures of physical function that were associated with changes in treatment outcomes. This emphasises the importance and value of assessing and adressing psychosocial factors, such as risk factors and resources, alongside performance-based measures in IMPT. Although challenging in naturalistic settings, future research should aim to implement research designs (e.g. randomized controlled designs) that allow for a better understanding of why changes occur following IMPT. Such insights would help further optimize pain management strategies in clinical practice. Declarations Acknowledgment We greatly appreciate the expertise of Prof. Dr. Christoph Stein during the editing process of the manuscript. Data availability statement: The participants of this study did not give written consent for their data to be shared publicly, so due to the sensitive nature of the research supporting data can not be shared publicly. References Elbers S, Wittink H, Konings S, et al. Longitudinal outcome evaluations of Interdisciplinary Multimodal Pain Treatment programmes for patients with chronic primary musculoskeletal pain: a systematic review and meta-analysis. Eur J Pain 2022;26:310-335. Waterschoot FPC, Dijkstra PU, Hollak N, et al. Dose or content? Effectiveness of pain rehabilitation programs for patients with chronic low back pain: a systematic review. Pain 2014;155:179-189. Kaiser U, Treede R-D, Sabatowski R. Multimodal pain therapy in chronic noncancer pain- gold standard or need for further clarification? Pain 2017;158:1853-1859. Kamper SJ, Apeldoorn AT, Chiarotto A, et al. Multidisciplinary biopsychosocial rehabilitation for chronic low back pain: cochrane systematic review and meta-analysis. BMJ 2015;350:h444. Gatchel RJ, Okifuji A. Evidence-based scientific data documenting the treatment and cost-effectiveness of comprehensive pain programs for chronic nonmalignant pain. J Pain 2006;7:779-793. Guzmán J, Esmail R, Karjalainen K, et al. Multidisciplinary rehabilitation for chronic low back pain: systematic review. BMJ 2001;322:1511-1516. Haldorsen EM, Grasdal AL, Skouen JS, et al. Is there a right treatment for a particular patient group? Comparison of ordinary treatment, light multidisciplinary treatment, and extensive multidisciplinary treatment for long-term sick-listed employees with musculoskeletal pain. Pain 2002;95:49-63. Boonstra AM, Reneman MF, Waaksma BR, et al. Predictors of multidisciplinary treatment outcome in patients with chronic musculoskeletal pain. Disabil Rehabil 2015;37:1242-1250. de Rooij A, van der Leeden M, Roorda LD, et al. Predictors of outcome of multidisciplinary treatment in chronic widespread pain: an observational study. BMC Musculoskelet Disord 2013;14:133. Pagé MG, Romero Escobar EM, Ware MA, et al. Predicting treatment outcomes of pain patients attending tertiary multidisciplinary pain treatment centers: a pain trajectory approach. Can J Pain 2017;1:61-74. Pfingsten M, Hildebrandt J, Saur P, et al. Multidisciplinary treatment program on chronic low back pain, part 4. Prognosis of treatment outcome and final conclusions. Schmerz 1997;11:30-41. Sandweg R, Bernardy K, Riedel H. Predictors of therapeutic success in inpatient psychosomatic rehabilitation of musculo-skeletal diseases. Psychother Psychosom Med Psychol 2001;51:394-402. Cormier S, Lavigne GL, Choiniere M, et al. Expectations predict chronic pain treatment outcomes. Pain 2016;157:329-338. Samwel HJ, Kraaimaat FW, Crul BJ, et al. Multidisciplinary allocation of chronic pain treatment: effects and cognitive-behavioural predictors of outcome. Br J Health Psychol 2009;14:405-421. Daenen L, Varkey E, Kellmann M, et al. Exercise, not to exercise, or how to exercise in patients with chronic pain? Applying science to practice. Clin J Pain 2015;31:108-114. Cunningham NR, Kashikar-Zuck S. Nonpharmacological treatment of pain in rheumatic diseases and other musculoskeletal pain conditions. Curr Rheumatol Rep 2013;15:306. American Society of Anesthesiologists Task Force on Chronic Pain Management. Practice guidelines for chronic pain management: an updated report by the American Society of Anesthesiologists Task Force on Chronic Pain Management and the American Society of Regional Anesthesia and Pain Medicine. Anesthesiology 2010;112:810-833. Kurklinsky S, Perez RB, Lacayo ER, et al. The efficacy of interdisciplinary rehabilitation for improving function in people with chronic pain. Pain Res Treat 2016;1: 7217684. Moradi B, Benedetti J, Zahlten-Hinguranage A, et al. The value of physical performance tests for predicting therapy outcome in patients with subacute low back pain: a prospective cohort study. Eur Spine J 2009;18:1041-1049. Wessels T, van Tulder M, Sigl T, et al. What predicts outcome in non-operative treatments of chronic low back pain? A systematic review. Eur Spine J 2006;15:1633-1644. Mannion AF, Dvorak J, Taimela S, et al. Increase in strength after active therapy in chronic low back pain (CLBP) patients: muscular adaptations and clinical relevance. Schmerz 2001;15:468-473. Kaiser U, Treede R-D, Sabatowski R. Multimodal pain therapy in chronic noncancer pain- gold standard or need for further clarification? Pain 2017;158:1853-1859. Michie S, Richardson M, Johnston M, et al. The behavior change technique taxonomy (v1) of 93 hierarchically clustered techniques: building an international consensus for the reporting of behavior change interventions. Ann Behav Med 2013;46:81-95. Fleig L, Labudek S, Warner L. Verhalten ändern, aber wie? Eine Übersicht für Praxis und Wissenschaft I Eine deutsche Übersetzung der Taxonomie der Techniken der Verhaltensänderung Version 1 von Michie et al. (2013). 2024. Available at: osf.io/w4pqh. Accessed December 9, 2024. Tate DF, Lytle LA, Sherwood NE, et al. Deconstructing interventions: approaches to studying behavior change techniques across obesity interventions. Transl Behav Med 2016;6:236-243. Nagel B, Gerbershagen H, Lindena G, et al. Development and evaluation of the multidimensional German pain questionnaire. Schmerz 2002;4:263-270. Von Korff M, Ormel J, Keefe FJ, et al. Grading the severity of chronic pain. Pain 1992;50:133-149. Klasen BW, Hallner D, Schaub C, et al. Validation and reliability of the German version of the Chronic Pain Grade questionnaire in primary care back pain patients. Psychosoc Med 2004;1:Doc07. Bracher ES, Pietrobon R, & Eluf-Neto J. Cross-cultural adaptation and validation of a Brazilian Portuguese version of the chronic pain grade. Quality of Life Research 2010; 19: 847-852. Buchholz I, Feng YS, Buchholz M, et al. Translation and adaptation of the German version of the Veterans Rand-36/12 Item Health Survey. Health Qual Life Outcomes 2021;19:137. Hüppe M, Schneider K, Casser HR, et al. Characteristic values and test statistical goodness of the Veterans RAND 12-Item Health Survey (VR-12) in patients with chronic pain : An evaluation based on the KEDOQ pain dataset. Schmerz 2022;36:109-120. Basler H-D. The Marburg questionnaire on habitual health findings – a study on patients with chronic pain. Schmerz 1999;13:385-391. Nilges P, Essau C. Depression, anxiety and stress scales: DASS- a screening procedure not only for pain patients. Schmerz 2015;29:649-657. Raschner C, Lembert S, Platzer HP, et al. S3-Check- evaluation and generation of normal values of a test for balance ability and postural stability. Sportverletz Sportschaden 2008;22:100-105. Tan H, Aziz A, Teh K, et al. Reliability of the stair-climb test (SCT) of cardiorespiratory fitness. Adv Exerc Sports Physiol 2004;10:77-83. Bennell K, Dobson F, Hinman R. Measures of physical performance assessments: Self-Paced Walk Test (SPWT), Stair Climb Test (SCT), Six-Minute Walk Test (6MWT), Chair Stand Test (CST), Timed Up & Go (TUG), Sock Test, Lift and Carry Test (LCT), and Car Task. Arthritis Care Res (Hoboken) 2011;63 Suppl 11:S350-370. Schellenberg KL, Lang JM, Chan KM, et al. A clinical tool for office assessment of lumbar spine stabilization endurance: prone and supine bridge maneuvers. Am J Phys Med Rehabil 2007;86:380-386. Bohannon RW, Steffl M, Glenney SS, et al. The prone bridge test: performance, validity, and reliability among older and younger adults. J Bodyw Mov Ther 2018;22:385-389. Durall CJ, Greene PF, Kernozek TW. A comparison of two isometric tests of trunk flexor endurance. J Strength Cond Res 2012;26:1939-1944. Cohen J. Statistical power analysis for the behavioural sciences. 2nd ed. New York, NY: Routledge; 1988. Gerdle B, Åkerblom S, Brodda Jansen G, et al. Who benefits from multimodal rehabilitation - an exploration of pain, psychological distress, and life impacts in over 35,000 chronic pain patients identified in the Swedish Quality Registry for Pain Rehabilitation. J Pain Res 2019;12:891-908. Pietilä Holmner E, Fahlstrom M, Nordstrom A. The effects of interdisciplinary team assessment and a rehabilitation program for patients with chronic pain. Am J Phys Med Rehabil 2013;92:77-83. Pöhlmann K, Tonhauser T, Joraschky P, et al. The Dachau multidisciplinary treatment program for chronic pain. Efficacy data of a diagnosis-independent multidisciplinary treatment program for back pain and other types of chronic pain. Schmerz 2009;23:40-46. Preis MA, Vogtle E, Dreyer N, et al. Long-term outcomes of a multimodal day-clinic treatment for chronic pain under the conditions of routine care. Pain Res Manag 2018;2018:9472104. Ringqvist Å, Dragioti E, Björk M, et al. Moderate and stable pain reductions as a result of interdisciplinary pain rehabilitation- a cohort study from the swedish quality registry for pain rehabilitation (SQRP). J Clin Med 2019;8. Ritchie CS, Patel K, Boscardin J, et al. Impact of persistent pain on function, cognition, and well-being of older adults. J Am Geriatr Soc 2023;71:26-35. Tseli E, Boersma K, Stalnacke BM, et al. Prognostic factors for physical functioning after multidisciplinary rehabilitation in patients with chronic musculoskeletal pain: a systematic review and meta-analysis. Clin J Pain 2019;35:148-173. Karayannis NV, Sturgeon JA, Chih-Kao M, et al. Pain interference and physical function demonstrate poor longitudinal association in people living with pain: a PROMIS investigation. Pain 2017;158:1063-1068. Greenberg J, Mace RA, Popok PJ, et al. Psychosocial correlates of objective, performance-based, and patient-reported physical function among patients with heterogeneous chronic pain. J Pain Res 2020;13:2255-2265. Bendix AF, Bendix T, Hæstrup C. Can it be predicted which patients with chronic low back pain should be offered tertiary rehabilitation in a functional restoration program? A search for demographic, socioeconomic, and physical predictors. Spine 1998;23:1775-1784. Steenstra IA, Munhall C, Irvin E, et al. Systematic review of prognostic factors for return to work in workers with sub acute and chronic low back pain. J Occup Rehabil 2017;27:369-381. van der Hulst M, Vollenbroek-Hutten MM, Ijzerman MJ. A systematic review of sociodemographic, physical, and psychological predictors of multidisciplinary rehabilitation-or, back school treatment outcome in patients with chronic low back pain. Spine 2005;30:813-825. Kroenke K, Wu J, Bair MJ, et al. Reciprocal relationship between pain and depression: a 12-month longitudinal analysis in primary care. J Pain 2011;12:964-973. Teh CF, Zaslavsky AM, Reynolds CF, 3rd, et al. Effect of depression treatment on chronic pain outcomes. Psychosom Med 2010;72:61-67. Parkitny L, McAuley JH, Walton D, et al. Rasch analysis supports the use of the depression, anxiety, and stress scales to measure mood in groups but not in individuals with chronic low back pain. J Clin Epidemiol 2012;65:189-198. Scascighini L, Toma V, Dober-Spielmann S et al. Multidisciplinary treatment for chronic pain: a systematic review of interventions and outcomes. Rheumatology 2008;47 : 670-678. Abberger B, Kieselbach K. Rasch analysis of the Depression, Anxiety, and Stress Scale in patients with chronic pain. J Psychosom Res 2024;178:111597. Aste JA. Chronic pain and stigma. A literature review [Doctoral dissertation]. Ann Arbour, MI: Union Institute and University; 2016. Rolli Salathé C, Elfering A. A health- and resource-oriented perspective on NSLBP. ISRN Pain 2013;2013:640690. Wilhelm LO, Lederle N, Diering L-E, et al. Linking physical activity to workers’ low back pain, back health, and theory-based psychological variables: study protocol of the workHealth intensive longitudinal observational study. BMC Public Health 2025;25:995. Bartley EJ, Ofri BL, Vasilopoulos T, et al. (2024). Promoting a foundation of resilience in older adults: pilot trial of a strengths-based positive psychology intervention for chronic low back pain. Health Psychol Behav Med, 2024;12:2434711. Eich W, Diezemann-Prossdorf A, Hasenbring M, et al. [Psychosocial factors in pain and pain management: a statement]. Schmerz 2023;37:159-167. Kaiser U, Nagel B, Petzke F, et al. [Prevention of chronic pain in the German healthcare system: current state and perspective]. Schmerz 2021;35:45-52. Fleig L, Radtke T, Dombrowski S. Understanding multiple health behaviours. In The Routledge International Handbook of Health Psychology (pp. 222-241). New York, NY: Routledge; 2025. López-Martínez AE, Esteve-Zarazaga R, Ramírez-Maestre C. Perceived social support and coping responses are independent variables explaining pain adjustment among chronic pain patients. J Pain 2008;9:373-379. Martinez-Calderon J, Zamora-Campos C, Navarro-Ledesma S, et al. The role of self-efficacy on the prognosis of chronic musculoskeletal pain: a systematic review. J Pain 2018;19:10-34. van der Hulst M, Vollenbroek-Hutten MM, Groothuis-Oudshoorn KG, et al. Multidisciplinary rehabilitation treatment of patients with chronic low back pain: a prognostic model for its outcome. Clin J Pain 2008;24:421-430. Furrer A, Michel G, Terrill AL, et al. Modeling subjective well-being in individuals with chronic pain and a physical disability: the role of pain control and pain catastrophizing. Disabil Rehabil 2019;41:498-507. Warner LM, Schwarzer R, Schuz B, et al. Health-specific optimism mediates between objective and perceived physical functioning in older adults. J Behav Med 2012;35:400-406. Fields HL. How expectations influence pain. Pain 2018;159 Suppl 1:S3-S10. Artus M, van der Windt DA, Jordan KP, et al. Low back pain symptoms show a similar pattern of improvement following a wide range of primary care treatments: a systematic review of randomized clinical trials. Rheumatology 2010;49:2346-2356. Lønn JH, Glomsrød B, Soukup MG, et al. Active back school: prophylactic management for low back pain. A randomized, controlled, 1-year follow-up study. Spine 1999;24:865-871. Table 2 Table 2 is available in the Supplementary Files section. Additional Declarations The authors declare no competing interests. Supplementary Files SupplementaryMaterial.docx TABLE2.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6865142","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":491445776,"identity":"f97bc442-e50c-4603-84d7-bb237f29396c","order_by":0,"name":"Jana Maas","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA80lEQVRIiWNgGAWjYBACxgYYi72BDUhKgJgGRGrhOQDWIkFQCwJIJLAxQK3Br4W5/ezBD4w5dvLyMx8/e/Bzj0UdPwPzxgd4HdaTlyzBuC3ZcMPtNHPDnmcSEpINbMV4rWFsyDEAamFm3CCdwybBc0BCwuAAj5kEXi39b4x/MG6rt58/8wyb5B+gFvsDPOY/8GqZkWMGtOVwYsMNHjZpsC0MPGb4dAC1vDGzSNx2PHnDmTQzaZkDEpIzDrMV43WYYX+O8Y2P26pt57cffib55kAdP39788YPeLU0AIkEFCFmvM5iYJAnID8KRsEoGAWjgIEBACsiRCQesA4mAAAAAElFTkSuQmCC","orcid":"https://orcid.org/0009-0003-4001-6066","institution":"","correspondingAuthor":true,"prefix":"","firstName":"Jana","middleName":"","lastName":"Maas","suffix":""},{"id":491445896,"identity":"0a72d6bc-7a3f-4fed-91d2-868c9ba28374","order_by":1,"name":"Stephan Vinzelberg","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Stephan","middleName":"","lastName":"Vinzelberg","suffix":""},{"id":491445897,"identity":"42ff0eb9-5ff1-4435-ac13-4a7006796819","order_by":2,"name":"Karolina Kolodziejczak-Krupp","email":"","orcid":"https://orcid.org/0000-0002-0310-1435","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Karolina","middleName":"","lastName":"Kolodziejczak-Krupp","suffix":""},{"id":491445898,"identity":"ce5cb147-9feb-44be-b9a2-3843242b90ea","order_by":3,"name":"Lea Wilhelm","email":"","orcid":"https://orcid.org/0000-0002-8564-8126","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Lea","middleName":"","lastName":"Wilhelm","suffix":""},{"id":491445899,"identity":"c1ce330b-7a86-47f2-a61f-4a614dc9e9d2","order_by":4,"name":"Lena Fleig","email":"","orcid":"https://orcid.org/0000-0002-5595-4587","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Lena","middleName":"","lastName":"Fleig","suffix":""}],"badges":[],"createdAt":"2025-06-10 16:40:24","currentVersionCode":1,"declarations":{"humanSubjects":true,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":true,"humanSubjectConsent":true,"humanSubjectClinicalTrial":true,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-6865142/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6865142/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":87933375,"identity":"c0fb4163-0393-4267-b2aa-fa466e67be81","added_by":"auto","created_at":"2025-07-30 13:58:10","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":46287,"visible":true,"origin":"","legend":"\u003cp\u003eMeasurement points of the longitudinal study to evaluate the interdisciplinary multimodal pain therapy. \u003cem\u003eNote\u003c/em\u003e. T = Time\u003c/p\u003e","description":"","filename":"Timeline.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6865142/v1/a938010152bc90f9550d2fec.jpg"},{"id":87933377,"identity":"22a4bff1-f4fe-44da-a86f-97e899794a36","added_by":"auto","created_at":"2025-07-30 13:58:10","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":55579,"visible":true,"origin":"","legend":"\u003cp\u003eFlowchart of the study.\u003c/p\u003e","description":"","filename":"Flowchart.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6865142/v1/c53da9c6afa3f39ac6719cad.jpg"},{"id":87934940,"identity":"48b78dee-1d80-44d0-8222-a810b9ca8135","added_by":"auto","created_at":"2025-07-30 14:14:10","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1313533,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6865142/v1/069d5f77-7dd0-4e97-a493-8793639c0a8b.pdf"},{"id":87933706,"identity":"98ab9cf1-2fb3-43fa-9859-75890a734213","added_by":"auto","created_at":"2025-07-30 14:06:10","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":31339,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryMaterial.docx","url":"https://assets-eu.researchsquare.com/files/rs-6865142/v1/1075a92eeafe3664922de579.docx"},{"id":87933374,"identity":"3ca3cb95-eb91-49c6-b696-ba9a49640ef6","added_by":"auto","created_at":"2025-07-30 13:58:10","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":22785,"visible":true,"origin":"","legend":"","description":"","filename":"TABLE2.docx","url":"https://assets-eu.researchsquare.com/files/rs-6865142/v1/93269e6d05fcf790bda8d55f.docx"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003eInterdisciplinary Multimodal Pain Therapy for chronic musculoskeletal pain in a day clinic setting: Examining patient-reported and performance-based correlates of treatment outcomes\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe long-term effectiveness of interdisciplinary multimodal pain therapy (IMPT) in treating chronic pain has been demonstrated repeatedly\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e. IMPT is a complex intervention incorporating different treatment components provided by a multidsiciplinary team\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e and has been shown to lead to reductions in pain, improvements in functional ability, a faster return to work, and appears to be cost-effective \u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan additionalcitationids=\"CR5 CR6\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e. The primary treatment outcomes of IMPT usually include self-reported, pain-related outcomes. However, to optimise IMPT, evaluations need to consider not only whether individuals benefit from the intervention (e.i. is the intervention effective?), but also why they benefit from it. The first step in answering the latter question is to a) assess potential mediators of treatment effects and b) analyse whether changes in these mediators are associated with changes in treatment outcomes (i.e. pain intensity, pain-related disability). Prior research has indicated that patients with high pain intensity levels benefit from IMPT\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e,\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e. Furthermore, sociodemographic factors such as gender, age, and work status have been shown to correlate with treatment outcomes. For example being younger\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e, being male\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e, and having a shorter duration of sick leave\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e,\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e were associated with greater improvements in pain. With regard to psychological variables, changes in pain intensity measures after IMPT have been shown to correlate with improvements in risk factors, such as depression and catastrophizing\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e and to be associated with positive treatment expectations\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e and higher acceptance of one\u0026rsquo;s condition\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eDaenen et al.\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e describe exercise therapy as a fundamental part of the conservative treatment of chronic musculoskeletal pain and most IMPTs also specifically aim to improve patients' physical functioning in order to reduce pain\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e. Guidelines for managing chronic pain recommend exercise as an important treatment modality\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e and performance-based measured of physical function have been shown to improve following IMPT\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e,\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e. However, previous research into the relationship between pain-related treatment outcomes and performance-based measures of physical function, has produced incosistent results. While some studies have shown that changes in physical function, such as strength and endurance, correlate with changes in pain following treatment\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e, other studies have shown that performance-based measures of physical function are unrelated to improvements in pain intensity and disability\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eThis study therefore uses routine care data from an established IMST in a day clinic setting to a) evaluate the IMPT in terms of pain-related primary treatment outcomes (i.e. pain intensity, pain-related disability), b) evaluate the IMPT in terms of potential patient-reported and performance-based mediators of treatment effects, and c) examine the extent to which patient-reported and performance-based variables are associated with changes in pain-related treatment outcomes. It was hypothesised that reductions in pain intensity and pain-related disability, as well as improvements in self-reported measures of mental and physical health, would be observed six months after the IMPT program.We also hypothesized that there would be an improvement in objective, performance-based measures of physical function following IMPT. Secondly, we hypothesized that both changes in mental and physical health, as well as parameters of physical function would be associated with changes in pain intensity and pain-related disability.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003e\u003cstrong\u003eEthical approval, trial registration\u003c/strong\u003e\u003c/p\u003e\u003cp\u003e The Ethics Committee of the MSB Medical School Berlin approved the study on 05/05/2025 (approval number MSB-2025/246). The study was registered retrospectively in the German Clinical Trials Register (DRKS00036855), which is also available on the International Clinical Trials Registry Platform.\u003c/p\u003e\u003cp\u003e\u003cb\u003eParticipants and procedure\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe present study is a single-arm pre-post intervention study. Participants were patients at a day clinic for manual medicine at the Sana Hospital Lichtenberg between November 2019 to August 2022. To be eligible for the IMPT program, patients had to have experienced chronic pain (at least three months) in the musculoskeletal system. This could include conditions such as back pain, joint pain, and headaches. The aetiology of the pain had to be multifactorial, involving a combination of complex functional musculoskeletal findings, pathomorphological changes, and psychosocial factors. Further details on the inclusion and exclusion criteria can be found in the supplementary material S1. Eligibility for the IMPT programme was assessed during an outpatient diagnostic appointment, consisting of one-hour medical and psychological examinations. This included an evaluation of the patient's pain characteristics, physical function and psychosocial health. Between November 2019 and August 2022, 422 patients attended the diagnostic assessment, and 308 of these received a recommendation for IMPT at the day clinic. The remaining 114 patients were advised to pursue alternative treatment, such as inpatient IMPT or psychosomatic treatment. On average, patients had to wait two months after the diagnostic assessment before starting IMPT. All participants gave written informed consent for their data to be used to assess treatment quality. As part of this evaluation participants completed paper-pencil questionnaires at the time of their diagnostic appointment (T0), underwent physical performance tests to measure physical function at the start (T1) and end (T2) of IMPT, and were reassessed with questionnaires six months after treatment (T3). The study design is shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eInterdisciplinary multimodal pain therapy (IMPT)\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe patients were enrolled in an IMPT program, which was provided by a team of healthcare professionals with expertise in the treatment of pain. This complex treatment is understood as a conservative orthopaedic pain therapy approach that incorporates manual medicine-oriented diagnostics and therapy, physical training and cognitive behavioral psychotherapy. The program aims to restore and improve physical functioning and reduce pain-related disability and pain intensity. Patients participate in a four-week therapy program comprising 100 hours in total. The treatment plan was standardized for all patients and included strength training, endurance training, relaxation training and medical and psychological education on pain and pain management, among other things. An example of a weekly schedule can be found in the supplementary material 2. In addition to the group program (closed groups of up to eight), patients had weekly individual sessions with their reference therapists (physician, physiotherapist/sports therapist, psychologist). A daily one-hour team meeting was held to facilitate interdisciplinary communication between team members. A more detailed description of the IMPT, following the TIDieR-Rehab checklist (Signal et al., 2024), can be found in the supplementary material (see S1).\u003c/p\u003e\u003cp\u003e\u003cb\u003eCoding intervention content in pain therapy in behaviour change techniques\u003c/b\u003e\u003c/p\u003e\u003cp\u003eAs previous research has often lacked clarity regarding the exact implementation of the IMPT\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e, the IMPT content was coded post-hoc using a German version of the standard behaviour change taxonomy\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e,\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e. The purpose of the coding was to make IMPT more replicable and comparable. This taxonomy aims to systematically and reliably identify the content of behaviour change interventions using a list of 93 different behaviour change techniques (BCTs\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e). BCT refers to a measurable and irreducible element of an intervention that is designed to modify or influence the underlying processes regulating behavior\u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e. Treatment content was categorized into BCTs independently by two raters (JM, LF), then compared and adjusted in a consensus process. An overview of the BCTs used in the treatment is provided in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eContent, form of delivery and behavior change techniques (BCTs) of the intervention\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"8\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eContent\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMethod\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eProfession\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eOrganization / Setting\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eMaterial\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eBCT\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eTarget behavior\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003eAim of the intervention component\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDefinition of individual behavioral goals (incl. context, frequency, duration and/ or intensity)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFrontal teaching,\u003c/p\u003e\u003cp\u003egroup discussion,\u003c/p\u003e\u003cp\u003eone-on-one\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePhysicians,\u003c/p\u003e\u003cp\u003epsychologists,\u003c/p\u003e\u003cp\u003ephysiotherapists,\u003c/p\u003e\u003cp\u003esports therapists\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eConference room, treatment room\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ePresentation,\u003c/p\u003e\u003cp\u003ewriting material,\u003c/p\u003e\u003cp\u003eprinted individualized instructions\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eAction planning (1.4), goal setting (behavior) (1.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003ePhysical activity, nutrition, relaxation, sleep\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eFacilitate behavior change\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAnalysis of barriers for behavior change \u0026amp; development of strategies to overcome those\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFrontal teaching, group discussion, one-on-one\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePsychologists,\u003c/p\u003e\u003cp\u003ephysicians,\u003c/p\u003e\u003cp\u003ephysiotherapists,\u003c/p\u003e\u003cp\u003esports therapists\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eConference room, treatment room\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ePresentation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eProblem solving (1.2), social support (practical) (3.2), social support (emotional) (3.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003ePhysical activity, sleep, relaxation, nutrition, stress management\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eFacilitate behavior change\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFeedback on change in physical performance\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOne-on-one\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePhysicians,\u003c/p\u003e\u003cp\u003ephysiotherapists,\u003c/p\u003e\u003cp\u003esports therapists\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eTreatment room\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eVisual presentation of outcome\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eFeedback on outcomes of behavior (2.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003ePhysical activity\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eHelp patients build motivation\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eExploration of perceived causes of behavior \u0026amp; development of an explanatory model\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFrontal teaching, group discussion, one-on-one, physician\u0026rsquo;s round\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePhysicians,\u003c/p\u003e\u003cp\u003epsychologists,\u003c/p\u003e\u003cp\u003ephysiotherapists,\u003c/p\u003e\u003cp\u003esports therapists\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eConference room, treatment room\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ePresentation,\u003c/p\u003e\u003cp\u003ewriting material,\u003c/p\u003e\u003cp\u003eflipchart\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eRe-attribution (4.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eAdaptive Coping (instead of catastrophizing)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eReduce insecurity and increase self-efficacy for suitable behavior in patients\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eInformation on consequences of a variety of behaviors on physical \u0026amp; mental health \u0026amp; emotional well-being\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFrontal teaching, group discussion, one-on-one, physician\u0026rsquo;s round\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePhysicians,\u003c/p\u003e\u003cp\u003epsychologists,\u003c/p\u003e\u003cp\u003ephysiotherapists,\u003c/p\u003e\u003cp\u003esports therapists\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eConference room, treatment room\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ePresentation, \u003cem\u003eflipchart, work sheets\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eInformation about health consequences (5.1), emotional consequences (5.6), credible source (9.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003ePhysical activity, sleep, relaxation, nutrition, stress management\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eIncrease self-responsibility and motivation to implement health behavior\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eInstruction, demonstration and instigation of rehearsal of behavior\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFrontal teaching, modeling, one-on-one\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePhysicians,\u003c/p\u003e\u003cp\u003epsychologists,\u003c/p\u003e\u003cp\u003ephysiotherapists,\u003c/p\u003e\u003cp\u003esports therapists\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eConference room, treatment room, training room, outside\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ePresentation, \u003cem\u003evideo recordings\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eInstruction on how to perform behavior (4.1), demonstration of the behavior (6.1), behavioral practice / rehearsal (8.1), credible source (9.1)\u003c/p\u003e\u003cp\u003e\u003cem\u003ehabit formation (8.3), habit reversal (8.4), generalization of a target behavior (8.6), graded tasks (8.7)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003ePhysical activity, sleep, relaxation, nutrition, stress management, communication and decision-making skills\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eImprove patients\u0026rsquo; well-being and self-efficacy, reduce pain\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEncouragement of adherence to the use of drugs if necessary\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFrontal teaching, one-on-one, physician\u0026rsquo;s round\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePhysicians\u003c/p\u003e\u003cp\u003epsychologists\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eConference room, treatment room\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ePresentation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eCredible source (9.1), pharmacological support (11.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eUse of medication\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eImprove patients\u0026rsquo; well-being, reduce pain\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWorking out ways to reduce unpleasant feelings\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFrontal teaching, group discussion, one-on-one\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePsychologists\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eConference room, treatment room\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ePresentation, \u003cem\u003eflipchart, work sheets\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eReduce negative emotions (11.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eEmotion regulation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eImprove patients\u0026rsquo; well-being, reduce anxiety and stress\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWorking out ways to redirect attention from unwanted bodily sensations\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFrontal teaching, group discussion, one-on-one\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePsychologists\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eConference room, treatment room\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ePresentation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eDistraction (12.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eAdaptive coping with pain\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eReduce anxiety and pain intensity, increase self-efficacy\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTraining, manual therapy, \u003cem\u003eassistive aids (e.g. lumbar support), passive treatment methods (e.g. taping)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFrontal teaching, modeling, one-on-one\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePhysicians,\u003c/p\u003e\u003cp\u003epsychologists,\u003c/p\u003e\u003cp\u003ephysiotherapists,\u003c/p\u003e\u003cp\u003esports therapists\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eTreatment room, training room, outside\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eWritten instructions, \u003cem\u003eaudio- and video recordings\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eFeedback on behavior (2.2), body changes (12.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003ePhysical activity and relaxation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eImprove patients\u0026rsquo; well-being and self-efficacy, reduce pain\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCognitive (re-) structuring (e.g. change of view on disability)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFrontal teaching, group discussion, one-on-one\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePsychologists\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eConference room, treatment room\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cem\u003ework sheets\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eFraming / Reframing (13.2), \u003cem\u003ebehavioral experiments (4.4), monitoring of emotional consequences (5.4), exposure (7.7), incompatible beliefs (13.3)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eAdaptive Coping (instead of catastrophizing)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eReduce anxiety and pain intensity, increase self-efficacy\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMotivation and support of self-esteem\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFrontal teaching, group discussion, one-on-one\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePhysicians,\u003c/p\u003e\u003cp\u003epsychologists,\u003c/p\u003e\u003cp\u003ephysiotherapists,\u003c/p\u003e\u003cp\u003esports therapists\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eConference room, treatment room, training room, outside\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ePresentation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eVerbal persuasion about capability (15.1), \u003cem\u003emental rehearsal of successful performance (15.2), focus on past success (15.3), self-talk (15.4)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003ePhysical activity, sleep, relaxation, nutrition, stress management\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eHelp patients build motivation and self-efficacy\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"8\" nameend=\"c8\" namest=\"c1\"\u003e\u003cp\u003eItalics: This BCT, content or material is included in the treatment if necessary.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eSelf-report treatment outcomes\u003c/b\u003e\u003c/p\u003e\u003cp\u003eAt baseline (T0), demographic data were collected and patients were asked about the duration of their pain. Answers were given on a 6-point response scale (1\u0026thinsp;=\u0026thinsp;\u0026lt;\u0026thinsp;\u003cem\u003e1 month\u003c/em\u003e, 2\u0026thinsp;\u003cem\u003e=\u0026thinsp;1 month - \u0026frac12; year\u003c/em\u003e, 3 \u003cem\u003e= \u0026frac12; year \u0026ndash; 1 year\u003c/em\u003e, 4\u0026thinsp;=\u0026thinsp;\u003cem\u003e1 year \u0026ndash; 2 years\u003c/em\u003e, 5\u0026thinsp;=\u0026thinsp;\u003cem\u003e2 years \u0026ndash; 5 years, 6\u0026thinsp;=\u0026thinsp;\u0026gt;\u0026thinsp;5 years)\u003c/em\u003e. At follow-up assessment (T3), patients were asked to rate the perceived success of the treatment on a 6-point scale (1\u0026thinsp;=\u0026thinsp;\u003cem\u003every good\u003c/em\u003e, 2\u0026thinsp;=\u0026thinsp;\u003cem\u003egood\u003c/em\u003e, 3\u0026thinsp;=\u0026thinsp;\u003cem\u003esatisfactory\u003c/em\u003e, 4\u0026thinsp;=\u0026thinsp;\u003cem\u003eadequate\u003c/em\u003e, 5\u0026thinsp;=\u0026thinsp;\u003cem\u003einadequate\u003c/em\u003e, 6\u0026thinsp;=\u0026thinsp;\u003cem\u003einsufficient\u003c/em\u003e).\u003c/p\u003e\u003cp\u003eThe \u0026ldquo;pain questionnaire\u0026rdquo; of the German Pain Society, which encompasses several of the following measures, was used to collect data\u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003e\u003cem\u003ePrimary outcome measure: pain intensity and pain-related disability\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThe degree of pain intensity and pain-related disability were assessed using the validated German version of the Chronic Pain Grade questionnaire (CPG\u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e,\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e). Patients were asked to rate their pain intensity (current pain intensity; maximum and average pain intensity within the past four weeks) and their pain-related disability within the past three months (with regard to daily activities, leisure activities, and ability to work) using six 11-point numeric rating scales. The response scales ranged from 0 (\u003cem\u003eno pain/no impairment)\u003c/em\u003e to 10 (\u003cem\u003emost severe pain/no activity possible\u003c/em\u003e). An additional item asked about the number of days in the past three months (six months in the original publication) during which the patient was unable to perform usual activities due to pain. The primary outcome variables were pain intensity (i.e., mean of current, average and maximum pain intensity multiplied by 10; ranging 0-100) and pain-related disability (i.e., mean of impairment in daily activities, leisure activities and ability to work multiplied by ten; ranging 0-100). The CPG allows the consctruction of a total score for grading the pain severity (i.e., Pain Severity Grade; four-step grading of pain intensity and disability; ranging 0\u0026ndash;3). As it is often used to guide the selection of pain treatments and could provide an assessment of qualitative change, changes in pain severity grade were also evaluated. The German version has been shown to be reliable and valid\u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e, although only the Brazilian Portuguese translation of the questionnaire has been tested for test-retest reliability, demonstrating moderate agreement\u0026sup2;⁹.\u003c/p\u003e\u003cp\u003e\u003cem\u003ePhysical and mental health\u003c/em\u003e\u003c/p\u003e\u003cp\u003eSelf-reported physical and mental health were measured using the German version of the Veterans RAND 12-Item Health Survey (VR-12\u003csup\u003e30,31\u003c/sup\u003e). The response format of this instrument alternates between three (1\u0026thinsp;=\u0026thinsp;\u003cem\u003eyes, limited a lot\u003c/em\u003e to 3\u0026thinsp;=\u0026thinsp;\u003cem\u003eno, not limited at all\u003c/em\u003e), five (1\u0026thinsp;=\u0026thinsp;\u003cem\u003enever\u003c/em\u003e to 5\u0026thinsp;=\u0026thinsp;\u003cem\u003ealways\u003c/em\u003e or 1\u0026thinsp;=\u0026thinsp;\u003cem\u003eexcellent\u003c/em\u003e to 5\u0026thinsp;=\u0026thinsp;\u003cem\u003epoor\u003c/em\u003e) and six (1\u0026thinsp;=\u0026thinsp;\u003cem\u003ealways\u003c/em\u003e to 6\u0026thinsp;=\u0026thinsp;n\u003cem\u003eever\u003c/em\u003e) response options. The items are divided into two component scores: physical and mental health. All 12 items are included in the calculation of each subscale and weighted according to their relevance to its content. Higher subscores indicate a more positive self-assessment of health. The VR-2 has been validated with patients with chronic pain\u003csup\u003e\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003e\u003cem\u003eWell-being\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThe Marburg Questionnaire on Habitual Well-being (FW-7\u003csup\u003e32\u003c/sup\u003e) was used to measure general well-being as a unidimensional factor. Respondents were asked to rate their level of satisfaction with their everyday and job performance despite their pain on a scale of 0 to 5, with 0 indicating strong disagreement and 5 indicating strong agreement. They were also asked to rate their level of comfort in various situations. Higher FW-7 total scores indicate higher levels of well-being. Basler\u003csup\u003e\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u003c/sup\u003e reports high internal consistency, test-retest reliability, and external validity with measures of pain chronification.\u003c/p\u003e\u003cp\u003e\u003cem\u003eDepressive symptoms, anxiety, and stress\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThe short version of the Depression Anxiety Stress Scale (DASS) was used as a screening instrument to measure the subscales of depression, anxiety and stress, each with seven items (German version: Nilges \u0026amp; Essau\u0026sup3;\u0026sup3;). Items were rated on a 4-point scale (0\u0026thinsp;=\u0026thinsp;\u003cem\u003edid not apply to me at all\u003c/em\u003e to 3\u0026thinsp;=\u0026thinsp;\u003cem\u003eapplied to me very much or most of the time\u003c/em\u003e). Cut-off values of \u0026ge;\u0026thinsp;10 for depression, \u0026ge; 6 for anxiety, and \u0026ge;\u0026thinsp;10 for stress indicate an increased likelihood for the respective psychological condition. The internal consistency and construct validity of the depression and anxiety subscales were good in the study conducted by Nilges and Essau\u003csup\u003e\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003e\u003cb\u003ePerformance-based measures of physical function\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eBalance and body stability\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThe stability, sensorimotor regulation and symmetry test from Multifunktionale Trainingsger\u0026auml;te GmbH (MFT-S3-Check\u003csup\u003e\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u003c/sup\u003e; MFT Bodyteamwork GmbH, Vienna, Austria) was used. The measurement device consisted of a uniaxially mounted, unstable standing plate with an integrated sensor-controlled transducer and associated evaluation software. Participants were tasked with keeping the platform horizontal for 30 seconds. Normative values are available for men and women in different age groups so that the results of the test can be classified within a standardized reference system.The stability index can range from 1 (\u003cem\u003every good\u003c/em\u003e) to 9 (\u003cem\u003every poor\u003c/em\u003e). Scores below 5 are considered below average compared to the normative sample for all age groups. Raschner et al.\u003csup\u003e\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u003c/sup\u003e report high test-retest reliability and objectivity for the stability index.\u003c/p\u003e\u003cp\u003e\u003cem\u003ePhysical fitness\u003c/em\u003e\u003c/p\u003e\u003cp\u003eFor the stair climb test (SCT), which assesses physical fitness, patients were asked to climb the stairs to the fourth floor as quickly as possible\u003csup\u003e\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e\u003c/sup\u003e. The time taken to climb the stairs was measured by physiotherapists or sports therapists using a stopwatch. The number of steps was based on local conditions (72 steps), so no comparisons can be made with other populations. Test-retest reliability was high in previous studies and there is evidence of good construct and criterion validity\u003csup\u003e\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003e\u003cem\u003eTrunk muscle endurance\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThe prone bridge test was used to assess trunk muscle endurance\u003csup\u003e\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u003c/sup\u003e. Patients were positioned in a prone position with their elbows flexed at 90\u0026deg;, their legs extended, and their whole body aligned. They were then asked to lift their body off the floor (except for the arms and feet) and to hold this position for as long as possible. The test ended when the position was disturbed or the patient fell. The duration was recorded in seconds. This test has been shown to validly measure trunk muscle endurance, with high test-retest reliability\u003csup\u003e\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e,\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStatistical analysis\u003c/h2\u003e\u003cp\u003eThe mean and standard deviation of all variables were calculated, with the significance level set at alpha\u0026thinsp;=\u0026thinsp;.05 for each statistical analysis. Listwise deletion was used to adress missing data. For the dropout analyses, t-tests were used for interval-scaled variables and chi-squared tests were used for non-interval-scaled variables to compare values between participants who took part in the follow-up survey and those who did not. Changes in the self-reported measures of pain intensity and pain-related disability, well-being, physical and mental health, depression, anxiety and stress were evaluated by comparing baseline (T0) and follow-up (T3) measures using a series of dependent samples t-tests. Treatment outcomes for physical function (balance and stability, physical fitness and trunk muscle endurance) were assessed by comparing test scores at the beginning (T1) and end (T2) of the intervention. The subgroup of participants who took part in the physical performance tests at T1 and T2 was larger than the group who also completed the questionnaire at T3. This is why the sample size differs in these analyses. Effect sizes were calculated using Cohen's \u003cem\u003ed\u003c/em\u003e and interpreted as small (.2), medium (.5) or large (.8)\u003csup\u003e\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e\u003c/sup\u003e. Pearson correlation coefficients were used to assess the correlation between the primary outcome measures, and the other factors at the different time points. The results were then used to select the variables for the regression analysis. Hierarchical linear regressions were performed to examine the extent to which changes in well-being, physical health, depression, stress, and physical function were associated with changes in pain intensity and pain-related disability at follow-up (T3). As previous studies have found correlations between pain duration, gender, age, and work status and treatment outcomes, these were included as control variables in the analyses. There was no difference in the results when 'pain duration' was included as either dummy variables (with five dummy variables representing the six categories, with '\u0026gt;5 years' as the reference category, as this category occurred most frequently) or as a pseudo-metric variable. Therefore, we included it in the final model as a pseudo-metric variable.An additional outcome variable was calculated based on the pain severity grade. By comparing pain severity grades at T0 and T3, a dichotomous variable was created to indicate whether there had been \u0026ldquo;improvement by at least one grade\u0026rdquo; (=\u0026thinsp;1) or \u0026ldquo;no change/worsened\u0026rdquo; (=\u0026thinsp;reference category). Binary logistic regression was used to examine the extend to which well-being, physical health, depression, stress, and physical function were associated with pain grade progression vs. pain grade maintenance/regression. Complete case analysis was used. All analyses were performed using SPSS (version 28).\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cb\u003eDescriptive analyses\u003c/b\u003e\u003c/p\u003e\u003cp\u003eOf the 308 patients who started treatment, seven (2.3%) discontinued it. In six cases, this was due to the onset of another illness (e.g., Covid infection) which prevented participation. In one case, it was due to an increase in depressive symptomss following the abrupt cessation of antidepressant medication shortly before the start of treatment. Patients had various and sometimes multiple diagnoses with lumboischialgia (25.5%), chronic pain disorder with somatic and psychological factors (17.8%), low back pain (12.5%), and cervicobrachial syndrome (11.2%) being the most common. As shown in the flowchart (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e), the follow-up survey six months after the end of treatment (T3) was completed by 137 participants (44.5%).There was no significant difference in most variables between participants who completed only the initial questionnaire (=\u0026thinsp;drop-out participants) and those who completed both the initial and follow-up questionnaire (=\u0026thinsp;completers). However, completers had lower mean scores on the anxiety subscale of the DASS at baseline (\u003cem\u003eM\u003c/em\u003e\u0026thinsp;=\u0026thinsp;3.20) compared to drop-out participants (M\u0026thinsp;=\u0026thinsp;4.20), \u003cem\u003et\u003c/em\u003e(290)\u0026thinsp;=\u0026thinsp;2.39, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.017, \u003cem\u003ed\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.28. In the drop-out group, fewer participants were working compared to the completers, \u003cem\u003eχ\u003c/em\u003e\u0026sup2;(1, \u003cem\u003eN\u003c/em\u003e\u0026thinsp;=\u0026thinsp;290)\u0026thinsp;=\u0026thinsp;4.15, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.042. The following descriptive data refer to participants who completed the questionnaires both at T0 and T3 (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;137). However, completers had lower mean anxiety subscale scroes on the DASS at baseline (\u003cem\u003eM\u003c/em\u003e\u0026thinsp;=\u0026thinsp;3.20) than drop-out participants (M\u0026thinsp;=\u0026thinsp;4.20), \u003cem\u003et\u003c/em\u003e(290)\u0026thinsp;=\u0026thinsp;2.39, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.017, \u003cem\u003ed\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.28. Fewer participants in the drop-out groupwere working compared to the completers, \u003cem\u003eχ\u003c/em\u003e\u0026sup2;(1, \u003cem\u003eN\u003c/em\u003e\u0026thinsp;=\u0026thinsp;290)\u0026thinsp;=\u0026thinsp;4.15, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.042. The following descriptive data refer to participants who completed the questionnaires at both T0 and T3 (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;137). The mean age of the participants was 50\u0026thinsp;\u0026plusmn;\u0026thinsp;11 years and 69% (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;95) were women. At baseline (T0), 62% (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;75) of participants were working. The remaining participants were either on sick leave, retired, unemployed, or in education. The mean body mass index (BMI) was 25.96\u0026thinsp;\u0026plusmn;\u0026thinsp;4.83 kg/m\u003csup\u003e2\u003c/sup\u003e. At baseline (T0), 43 participants (34%) categorized the duration of their pain as \u0026gt;\u0026thinsp;5 years, 24 (19%) as 2\u0026ndash;5 years, 22 (18%) as 1\u0026ndash;2 years and 36 (29%) as 6 months \u0026minus;\u0026thinsp;1 year. The mean current pain intensity as measured by the first item of the CPG, was 5.74\u0026thinsp;\u0026plusmn;\u0026thinsp;1.72 (0\u0026ndash;10). At follow-up (T3) participants rated the program as follows: very good (32%), good (29%), satisfactory (20%), adequate (11%), inadequate (8%) and insufficient (0%). Correlations between the primary outcome measures, and the other factors at the different time points can be seen in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cb\u003eContent of the intervention\u003c/b\u003e\u003c/p\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e summarizes how the intervention content aligned with the identified BCTs. Of the 93 BCTs, 27 techniques were identified within the intervention at least once. The majority of the identified BCTs belonged to the clusters repetition and substitution (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;5), self-belief (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;4), goals and planning (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;3), and shaping knowledge (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;3; see Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cb\u003eChanges in the variables across time\u003c/b\u003e\u003c/p\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e shows changes in pain intensity, pain-related disability, well-being, physical and mental health, depression, anxiety, stress between baseline (T0) and follow-up (T3). Significant changes in the hypothesized direction were observed for all variables, with effect sizes ranging from small (\u003cem\u003ed\u003c/em\u003e=-.24 for mental health and \u003cem\u003ed\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.25 for anxiety)) to large (\u003cem\u003ed\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.90 for physical health, \u003cem\u003ed\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.95 for pain intensity). Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e also shows a comparison of physical function parameters at the start (T1) and end (T2) of treatment. Significant improvements were observed in all three measures, with the largest effect size (-1.12) seen in the change in trunk muscle endurance. Examining the distribution of CPG pain severity grades at baseline (T0) and follow-up (T3), it was found that 77 participants (65%) improved by at least one grade, 30 participants (25%) experienced no change, and 12 participants (10%) reported an increase in pain severity by at least one grade (see Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eChange in the variables over time\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"9\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eQuestionnaire\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eT0\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003eT3\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003eM\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003eSD\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003eM\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cem\u003eSD\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cem\u003et\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cem\u003edf\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c9\"\u003e\u003cp\u003eCohen\u0026rsquo;s \u003cem\u003ed\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePain intensity (CPG)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e62.24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e15.41\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e40.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e24.21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e10.39\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cem\u003e118\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e\u003cem\u003e\u0026lt;\u0026thinsp;.001\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e.95\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePain-related disability (CPG)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e54.80\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e23.15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e31.65\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e25.38\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e8.19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cem\u003e117\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e.75\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePhysical health (VR-12)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e33.31\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e9.63\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e43.53\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e10.78\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e-9.64\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cem\u003e115\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.90\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMental health (VR-12)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e35.48\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6.54\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e37.54\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e6.85\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cem\u003e-\u003c/em\u003e2.57\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cem\u003e115\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e.006\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.24\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWell-being (FW-7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e14.23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7.74\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e21.47\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e8.42\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e-8.30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cem\u003e121\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.75\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDepression (DASS)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6.68\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.63\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e4.26\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e4.28\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e6.25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cem\u003e119\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e.57\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAnxiety (DASS)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3.10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3.09\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2.44\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e3.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e2.70\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cem\u003e119\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e.004\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e.25\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eStress (DASS)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8.48\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.95\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e6.19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e4.74\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e5.39\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cem\u003e119\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e.49\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003ePhysical performance tests\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e\u003cb\u003eT1\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003e\u003cb\u003eT2\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eM\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003eSD\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003eM\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003eSD\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cb\u003et\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cb\u003edf\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e\u003cb\u003ep\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e\u003cb\u003eCohen\u0026rsquo;s\u003c/b\u003e \u003cb\u003ed\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBalance \u0026amp; Stability (MFT-S3-Check)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5.37\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.02\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e5.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.06\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e7.06\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cem\u003e256\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e.44\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePhysical fitness (SCT)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e40\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e15.70\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e35.45\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e13.27\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e9.80\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cem\u003e251\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e.62\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTrunk muscle endurance (prone bridge test)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e37.76\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e21.86\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e65.84\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e29.80\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e-16.89\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cem\u003e224\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e-1.12\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"9\" nameend=\"c9\" namest=\"c1\"\u003e\u003cp\u003eNote: CPG indicates Chronic Pain Grade; VR-12, Veterans RAND 12-Item Health Survey; FW-7, Marburg Questionnaire on Habitual Well-being; DASS, Depression Anxiety Stress Scale; SCT, stair climb test; 116\u0026thinsp;\u0026le;\u0026thinsp;n\u0026thinsp;\u0026le;\u0026thinsp;257 due to missing values.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eNumber of patients per pain severity grades based on von Korff28 at T1 and T3\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c2\" namest=\"c1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colspan=\"4\" nameend=\"c6\" namest=\"c3\"\u003e\u003cp\u003ePain severity grade (T3)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eTotal\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eI\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eII\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eIII\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eIV\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003e\u003cb\u003ePain severity\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003egrade (T0)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eI\u003c/b\u003e low intensity \u0026amp; low disability\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eII\u003c/b\u003e high intensity \u0026amp; low disability\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e48\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eIII\u003c/b\u003e high disability \u0026amp; moderately limiting\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e20\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eIV\u003c/b\u003e high disability \u0026amp; severely limiting\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e39\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e67\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e31\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e119\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e\u003cp\u003eNote. Grey background indicates improvement.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eCorrelates of changes in pain intensity and pain-related disability\u003c/b\u003e\u003c/p\u003e\u003cp\u003eMultiple regression analysis was used to test for significant associations between changes in self-reported psychological and performance-based physical parameters and changes in participants' pain intensity.. The results of the regression analysis, which controlled for pain duration, gender, age and work status, are shown in Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e. These results indicate that two variables explained 44.1% of the variance, \u003cem\u003eF\u003c/em\u003e(6,96)\u0026thinsp;=\u0026thinsp;12.60, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001. Specifically,changes in both self-reported physical health (VR-12) and change in well-being (FW7) were significantly associated with changes in pain intensity (B\u0026thinsp;=\u0026thinsp;1.11, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001, and B\u0026thinsp;=\u0026thinsp;0.73, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001, respectively). Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e also shows the results of the regression analysis in which change in reported pain-related disability was used as the dependent variable. Consistent with previous pattern, changes in physical health (B\u0026thinsp;=\u0026thinsp;1.65, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001) and change in well-being (B\u0026thinsp;=\u0026thinsp;1.48, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001) were significantly associated with changes in pain-related disability. Changes in depressive symptoms, stress and in the physical function parameters were not significantly related to the changes in pain intensity or pain-related disability.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003ePrediction of change in pain intensity\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"11\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colspan=\"5\" nameend=\"c6\" namest=\"c2\"\u003e\u003cp\u003eChange in pain intensity\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"5\" nameend=\"c11\" namest=\"c7\"\u003e\u003cp\u003eChange in pain-related disability\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePredictors\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eB\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003eSE\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003eR\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003eR\u003c/b\u003e\u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cb\u003eΔR\u0026sup2;\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cb\u003eB\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e\u003cb\u003eSE\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e\u003cb\u003eR\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e\u003cb\u003eR\u003c/b\u003e\u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e\u003cb\u003eΔR\u0026sup2;\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eStep 1:\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.27\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e.07\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e.03\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e.28\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e.08\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e.65\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDuration\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-3.84\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.65\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e-5.96\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e2.17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e.18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e.21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e.27\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGender\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.69\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.90\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e-2.96\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e6.11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWork-status\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-8.08\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.93\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e2.13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e6.47\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eStep 2:\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.61\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e.37***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e.33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e.67\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e.45***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e.42\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eChange in physical health\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1.11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e.17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1.65\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e.20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eStep 3:\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.66\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e.44***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e.41\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e.79\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e.63***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e.60\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eChange in well-being\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e.73\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e.21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1.48\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e.22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eStep 4:\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.66\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e.44\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e.39\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e.79\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e.63\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e.60\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eChange in depression\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e.57\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e.59\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e.61\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eChange in stress\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e.49\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.44\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e.53\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eStep 5:\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.67\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e.46\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e.39\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e.79\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e.63\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e.59\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eChange in balance and body stability\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2.52\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.47\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e-1.01\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e2.70\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eChange in physical fitness\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e.31\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e.09\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e.17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e.31\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eChange in trunk muscle endurance\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e.04\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e.08\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e.09\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"11\" nameend=\"c11\" namest=\"c1\"\u003e\u003cp\u003e* p\u0026thinsp;\u0026lt;\u0026thinsp;.05 ** p\u0026thinsp;\u0026lt;\u0026thinsp;.01 *** p\u0026thinsp;\u0026lt;\u0026thinsp;.001; \u003cem\u003eN\u003c/em\u003e\u0026thinsp;=\u0026thinsp;108\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eLogistic regression was used to analyse the association between changes in psychological and physical parameters and the likelihood of an improvement of at least one pain grade on the CPG (reference category 0 = \u0026ldquo;no change / worsened\u0026rdquo;). Together, the variables accounted for a significant amount of variance in the outcome; the likelihood ratio test comparing a full model with a reduced model resulted in a chi-squared value of 50.25, with a p-value of less than .001. Again, only change in physical health, \u003cem\u003eOR\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1.11 95% CI [1.03, 1.19], \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.006, and change in well-being \u003cem\u003eOR\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1.13, 95% CI [1.04, 1.23], \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.003, were independently associated with changes in the graduation of pain. The odds of a reduction in the CPG by at least one grade, compared to no change or worsening, increased by 11% for each one-point increase in self-reported physical health and by 13% for each one-point increase in self-reported well-being, when holding the other variables constant.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe overall aim of the present pre-post analysis was to evaluate an IMPT for individuals with chronic musculoskeletal pain in the context of routine day clinic care. This evaluation considered changes in patient-reported variables and performance-based measures (e.g., prone bridge test, SCT, MFT-S3-Check) after the intervention. As well as analysing changes in the primary treatment outcomes (i.e., pain intensity, pain-related disability), the study examined changes in potential mediators of the treatment effects, and their associations with the pain-related outcomes. Six months after treatment, reductions in pain intensity (CPG) and pain-related disability (CPG) were observed, with large and medium effect sizes, respectively.These findings align with previous research demonstrating the effectiveness of IMPT in reducing musculoskeletal pain \u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan additionalcitationids=\"CR42 CR43 CR44\" citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e\u003c/sup\u003e, further supporting its robustness as a therapeutic intervention for chronic pain. Regarding potential mediators, self-reported measures showed improvements in physical health (VR-12) with a large effect size, reductions in depressive symptoms (DASS) and improvements in general well-being (FW-7) with medium effect sizes, and reductions in stress, anxiety (DASS) and mental health (VR-12) with small effect sizes. Furthermore, performance-based measures showed improvements from the start to the end of treatment, with small to large effect sizes, suggesting that IMPT is associated with objectively measurable changes in physical function. Few participants (2.3%) dropped out of the treatment program, and satisfaction with the treatment remained high.\u003c/p\u003e\u003cp\u003e In terms of intervention content, healthcare professionals in the interdisciplinary treatment team most frequently used BCTs that focused on coping strategies (e.g., reattribution), advising patients on how to perform recommended health behaviours correctly (e.g., behavioural rehearsal of specific exercises), and motivating patients to engage in specific health behaviours (e.g., behavioural instruction, verbal persuasion of ability). BCTs that empower patients to regulate their own health behaviours in daily life (e.g., habit formation, action planning) were used less frequently, but would be a valuable addition to current IMPT programmes in order to support the sustainability of treatment effects.\u003c/p\u003e\u003cp\u003eRather than objective measures of physical function, changes in self-reported well-being and physical health were associated with changes in pain intensity, pain-related disability and pain grade classification. Contrary to other studies\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e,\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e,\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e,\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e, age was not associated with a reduction in pain intensity or disability and neither was pain duration, gender or work status. It is possible that there are bidirectional relationships between well-being, physical health and pain. For example, pain could negatively impact subjective health and well-being. A large study by Ritchie et al\u003csup\u003e\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e\u003c/sup\u003e found that persistent pain in older adults was associated with a decline in self-reported physical function and well-being over a seven years. However, a review examining prognostic factors for self-reported physical functioning (as measured by the VR-12) after an IMPT found that pain intensity was unrelated to physical functioning\u003csup\u003e\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e\u003c/sup\u003e. Karayannis et al.\u003csup\u003e\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e\u003c/sup\u003e used a parallel process latent growth curve modelling to study the relationship between pain interference and self-reported physical functioning. They found a weak one-way relationship between physical functioning and pain interference over 90 days. This suggests that changes in physical functioning are associated with changes in pain interference, rather than the other way around. Future studies should further examine whether improvements in self-reported parameters of physical health lead to pain reduction via specific pathways, such as increased mobility,enhanced mental health or improved well-being.\u003c/p\u003e\u003cp\u003eContrary to our hypotheses, changes in objective physical function parameters were not associated with improvements in pain intensity and disability. This is consistent with previous studies, in which pain correlated with self-reported disability, rather than performance-based measures\u003csup\u003e\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e\u003c/sup\u003e, and in which physical variables showed little prognostic value for outcome parameters\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e,\u003cspan additionalcitationids=\"CR51\" citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e\u003c/sup\u003e. In contrast to our hypotheses and unlike previous studies, where reductions in depressive symptoms coincided with reductions in pain⁵\u0026sup3;\u003csup\u003e,\u003c/sup\u003e⁵⁴reductions in anxiety, depressive symptoms and stress did not correspond with pain reductions. Additionally, the effect size for changes in mental health and anxiety at follow-up compared to baseline scores was smaller than for the other variables. These differing results may be due to differences in the study population, methodology or types of intervention used. This suggests that the relationship between mental health and pain may not be universal across all contexts.The mean scores for depression, anxiety and stress (DASS) by the sample in this study were lower than in a population with chronic low back pain using the same questionnaire\u003csup\u003e\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e\u003c/sup\u003e, which limits the potential for improvement after the intervention. Compared to other multimodal outpatient treatment programs this treatment was relatively short but intensive\u003csup\u003e\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e\u003c/sup\u003e. In a systematic review, Scascighini et al.\u003csup\u003e\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e\u003c/sup\u003e did, however, not find a significant relationship between the treatment duration and success. Present findings should be replicated using additional patient-reported measures to assess depressive symptoms, as recent studies have suggested that the psychometric properties of the DASS may be limited. \u003csup\u003e\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e\u003c/sup\u003e. When comparing the questionnaires used in this study to assess different aspects of mental health (DASS, VR-12, FW-7), the DASS and VR-12 are more deficit-oriented than the FW-7. This distinction is particularly relevant given that one of the stigmas feared by people with chronic pain is psychologisation\u003csup\u003e\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e58\u003c/span\u003e\u003c/sup\u003e, which may lead to a reluctance to respond positively to items that address mental health problems specifically. At a content level, the associations between changes in well-being (FW-7) and changes in pain intensity and pain-related disability found in this study, may also support a greater focus on potential protective resources that help individuals to become and /or remain healthy\u003csup\u003e\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e58\u003c/span\u003e,\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e59\u003c/span\u003e,\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e60\u003c/span\u003e\u003c/sup\u003e. As well as targeting mental health outcomes such as depression, IMPT should specifically target resources and theory-based, psychological risk factors of pain chronification\u003csup\u003e\u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e61\u003c/span\u003e,\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e62\u003c/span\u003e\u003c/sup\u003e. At the behavioural level, researchers may also consider measuring the extent to which individuals adhere to health behaviours relevant to pain management (e.g. physical activity, relaxation techniques). As such, IMPT can be understood as a multiple behaviour intervention\u003csup\u003e\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e63\u003c/span\u003e\u003c/sup\u003e and it is likely that multiple behaviour changes contribute to treatment success. Factors that potentially contribute to this but were not assessed in this study include catastrophizing, fear-avoidance behaviour, self-efficacy, expectations, and perceived social support\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e,\u003cspan additionalcitationids=\"CR65\" citationid=\"CR65\" class=\"CitationRef\"\u003e64\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e66\u003c/span\u003e\u003c/sup\u003e. In a study done by Furrer et al.\u003csup\u003e\u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e67\u003c/span\u003e\u003c/sup\u003e, pain catastrophizing mediated the effect of subjective well-being on pain intensity and pain interference. Optimism is one of factor that has been shown to be associated with self-reported physical functioning\u003csup\u003e\u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e68\u003c/span\u003e\u003c/sup\u003e. Exercise training and subsequent improvements in physical function may influence pain intensity and disability through changes in pain processing, self-efficacy, motivation and mood\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eThe study design of the present study has some limitations. The data of the current study were collected in a naturalistic setting of a day clinic. A major limitation of this study is the lack of randomized control groups (e.g. alternative pain treatment or no intervention). Additionally, there was an asymmetric timing of the assessments: unlike the physical performance tests, the questionnaire data were collected at the six-month follow-up, rather than post-treatment due to clinic logistics. So while the external validity of our results is high, we cannot make any causal inferences about the observed changes following the treatment. The response rate to the follow-up survey was low, and those who participated in the follow-up survey differed from those who dropped out in terms of anxiety levels and work status. This leaves room for non-response bias and limits generalizability. The initial questionnaire survey was conducted approximately two months prior to the start of IMPT, during which time symptoms may have changed, for example, due to expectations of treatment\u003csup\u003e\u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e69\u003c/span\u003e\u003c/sup\u003e. In other studies, a decrease in pain and passive pain coping strategies was observed during the waiting period\u003csup\u003e\u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e70\u003c/span\u003e,\u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e71\u003c/span\u003e\u003c/sup\u003e. As the patient group was diverse, with pain in various musculoskeletal areas, results may vary by subgroup andthe standardized nature of the program may not fully address patients\u0026rsquo; diverse needs. Future evaluations should include longer follow-up periods to examine IMPT sustainability and assess patient adherence, since long-term adherence to exercise programs has been demonstrated to be challenging for patients\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eIn conclusion, the results of this study suggest that individuals with chronic musculoskeletal pain can benefit from IMPT in routine caresettings. This improvement was evident in both pain-specific outcomes (i.e. pain intensity and disability) and physical function, well-being, and mental and physical health. However, it was changes in self-reported well-being and physical health rather than in performance-based measures of physical function that were associated with changes in treatment outcomes. This emphasises the importance and value of assessing and adressing psychosocial factors, such as risk factors and resources, alongside performance-based measures in IMPT. Although challenging in naturalistic settings, future research should aim to implement research designs (e.g. randomized controlled designs) that allow for a better understanding of why changes occur following IMPT. Such insights would help further optimize pain management strategies in clinical practice.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgment\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe greatly appreciate the expertise of Prof. Dr. Christoph Stein during the editing process of the manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability statement: \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe participants of this study did not give written consent for their data to be shared publicly, so due to the sensitive nature of the research supporting data can not be shared publicly. \u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eElbers S, Wittink H, Konings S, et al. Longitudinal outcome evaluations of Interdisciplinary Multimodal Pain Treatment programmes for patients with chronic primary musculoskeletal pain: a systematic review and meta-analysis. \u003cem\u003eEur J Pain\u003c/em\u003e 2022;26:310-335.\u003c/li\u003e\n\u003cli\u003eWaterschoot FPC, Dijkstra PU, Hollak N, et al. Dose or content? Effectiveness of pain rehabilitation programs for patients with chronic low back pain: a systematic review. \u003cem\u003ePain\u003c/em\u003e 2014;155:179-189.\u003c/li\u003e\n\u003cli\u003eKaiser U, Treede R-D, Sabatowski R. Multimodal pain therapy in chronic noncancer pain- gold standard or need for further clarification? \u003cem\u003ePain\u003c/em\u003e 2017;158:1853-1859.\u003c/li\u003e\n\u003cli\u003eKamper SJ, Apeldoorn AT, Chiarotto A, et al. Multidisciplinary biopsychosocial rehabilitation for chronic low back pain: cochrane systematic review and meta-analysis. \u003cem\u003eBMJ\u003c/em\u003e 2015;350:h444.\u003c/li\u003e\n\u003cli\u003eGatchel RJ, Okifuji A. Evidence-based scientific data documenting the treatment and cost-effectiveness of comprehensive pain programs for chronic nonmalignant pain. \u003cem\u003eJ Pain\u003c/em\u003e 2006;7:779-793.\u003c/li\u003e\n\u003cli\u003eGuzm\u0026aacute;n J, Esmail R, Karjalainen K, et al. Multidisciplinary rehabilitation for chronic low back pain: systematic review. \u003cem\u003eBMJ\u003c/em\u003e 2001;322:1511-1516.\u003c/li\u003e\n\u003cli\u003eHaldorsen EM, Grasdal AL, Skouen JS, et al. Is there a right treatment for a particular patient group? Comparison of ordinary treatment, light multidisciplinary treatment, and extensive multidisciplinary treatment for long-term sick-listed employees with musculoskeletal pain. \u003cem\u003ePain\u003c/em\u003e 2002;95:49-63.\u003c/li\u003e\n\u003cli\u003eBoonstra AM, Reneman MF, Waaksma BR, et al. Predictors of multidisciplinary treatment outcome in patients with chronic musculoskeletal pain. \u003cem\u003eDisabil Rehabil\u003c/em\u003e 2015;37:1242-1250.\u003c/li\u003e\n\u003cli\u003ede Rooij A, van der Leeden M, Roorda LD, et al. Predictors of outcome of multidisciplinary treatment in chronic widespread pain: an observational study. \u003cem\u003eBMC Musculoskelet Disord\u003c/em\u003e 2013;14:133.\u003c/li\u003e\n\u003cli\u003ePag\u0026eacute; MG, Romero Escobar EM, Ware MA, et al. Predicting treatment outcomes of pain patients attending tertiary multidisciplinary pain treatment centers: a pain trajectory approach. \u003cem\u003eCan J Pain\u003c/em\u003e 2017;1:61-74.\u003c/li\u003e\n\u003cli\u003ePfingsten M, Hildebrandt J, Saur P, et al. Multidisciplinary treatment program on chronic low back pain, part 4. Prognosis of treatment outcome and final conclusions. \u003cem\u003eSchmerz\u003c/em\u003e 1997;11:30-41.\u003c/li\u003e\n\u003cli\u003eSandweg R, Bernardy K, Riedel H. Predictors of therapeutic success in inpatient psychosomatic rehabilitation of musculo-skeletal diseases. \u003cem\u003ePsychother Psychosom Med Psychol\u003c/em\u003e 2001;51:394-402.\u003c/li\u003e\n\u003cli\u003eCormier S, Lavigne GL, Choiniere M, et al. Expectations predict chronic pain treatment outcomes. \u003cem\u003ePain\u003c/em\u003e 2016;157:329-338.\u003c/li\u003e\n\u003cli\u003eSamwel HJ, Kraaimaat FW, Crul BJ, et al. Multidisciplinary allocation of chronic pain treatment: effects and cognitive-behavioural predictors of outcome. \u003cem\u003eBr J Health Psychol\u003c/em\u003e 2009;14:405-421.\u003c/li\u003e\n\u003cli\u003eDaenen L, Varkey E, Kellmann M, et al. Exercise, not to exercise, or how to exercise in patients with chronic pain? Applying science to practice. \u003cem\u003eClin J Pain\u003c/em\u003e 2015;31:108-114.\u003c/li\u003e\n\u003cli\u003eCunningham NR, Kashikar-Zuck S. Nonpharmacological treatment of pain in rheumatic diseases and other musculoskeletal pain conditions. \u003cem\u003eCurr Rheumatol Rep\u003c/em\u003e 2013;15:306.\u003c/li\u003e\n\u003cli\u003eAmerican Society of Anesthesiologists Task Force on Chronic Pain Management. Practice guidelines for chronic pain management: an updated report by the American Society of Anesthesiologists Task Force on Chronic Pain Management and the American Society of Regional Anesthesia and Pain Medicine. \u003cem\u003eAnesthesiology\u003c/em\u003e 2010;112:810-833.\u003c/li\u003e\n\u003cli\u003eKurklinsky S, Perez RB, Lacayo ER, et al. The efficacy of interdisciplinary rehabilitation for improving function in people with chronic pain. \u003cem\u003ePain Res Treat\u003c/em\u003e 2016;1: 7217684.\u003c/li\u003e\n\u003cli\u003eMoradi B, Benedetti J, Zahlten-Hinguranage A, et al. The value of physical performance tests for predicting therapy outcome in patients with subacute low back pain: a prospective cohort study. \u003cem\u003eEur Spine J\u003c/em\u003e 2009;18:1041-1049.\u003c/li\u003e\n\u003cli\u003eWessels T, van Tulder M, Sigl T, et al. What predicts outcome in non-operative treatments of chronic low back pain? A systematic review. \u003cem\u003eEur Spine J\u003c/em\u003e 2006;15:1633-1644.\u003c/li\u003e\n\u003cli\u003eMannion AF, Dvorak J, Taimela S, et al. Increase in strength after active therapy in chronic low back pain (CLBP) patients: muscular adaptations and clinical relevance. \u003cem\u003eSchmerz\u003c/em\u003e 2001;15:468-473.\u003c/li\u003e\n\u003cli\u003eKaiser U, Treede R-D, Sabatowski R. Multimodal pain therapy in chronic noncancer pain- gold standard or need for further clarification? \u003cem\u003ePain\u003c/em\u003e 2017;158:1853-1859.\u003c/li\u003e\n\u003cli\u003eMichie S, Richardson M, Johnston M, et al. The behavior change technique taxonomy (v1) of 93 hierarchically clustered techniques: building an international consensus for the reporting of behavior change interventions. \u003cem\u003eAnn Behav Med\u003c/em\u003e 2013;46:81-95.\u003c/li\u003e\n\u003cli\u003eFleig L, Labudek S, Warner L. Verhalten \u0026auml;ndern, aber wie? Eine \u0026Uuml;bersicht f\u0026uuml;r Praxis und Wissenschaft I Eine deutsche \u0026Uuml;bersetzung der Taxonomie der Techniken der Verhaltens\u0026auml;nderung Version 1 von Michie et al. (2013). 2024. Available at: osf.io/w4pqh. Accessed December 9, 2024.\u003c/li\u003e\n\u003cli\u003eTate DF, Lytle LA, Sherwood NE, et al. Deconstructing interventions: approaches to studying behavior change techniques across obesity interventions. \u003cem\u003eTransl Behav Med\u003c/em\u003e 2016;6:236-243.\u003c/li\u003e\n\u003cli\u003eNagel B, Gerbershagen H, Lindena G, et al. Development and evaluation of the multidimensional German pain questionnaire. \u003cem\u003eSchmerz\u003c/em\u003e 2002;4:263-270.\u003c/li\u003e\n\u003cli\u003eVon Korff M, Ormel J, Keefe FJ, et al. Grading the severity of chronic pain. \u003cem\u003ePain\u003c/em\u003e 1992;50:133-149.\u003c/li\u003e\n\u003cli\u003eKlasen BW, Hallner D, Schaub C, et al. Validation and reliability of the German version of the Chronic Pain Grade questionnaire in primary care back pain patients. \u003cem\u003ePsychosoc Med\u003c/em\u003e 2004;1:Doc07.\u003c/li\u003e\n\u003cli\u003eBracher ES, Pietrobon R, \u0026amp; Eluf-Neto J. Cross-cultural adaptation and validation of a Brazilian Portuguese version of the chronic pain grade. \u003cem\u003eQuality of Life Research \u003c/em\u003e2010; 19: 847-852.\u003c/li\u003e\n\u003cli\u003eBuchholz I, Feng YS, Buchholz M, et al. Translation and adaptation of the German version of the Veterans Rand-36/12 Item Health Survey. \u003cem\u003eHealth Qual Life Outcomes\u003c/em\u003e 2021;19:137.\u003c/li\u003e\n\u003cli\u003eH\u0026uuml;ppe M, Schneider K, Casser HR, et al. Characteristic values and test statistical goodness of the Veterans RAND 12-Item Health Survey (VR-12) in patients with chronic pain : An evaluation based on the KEDOQ pain dataset. \u003cem\u003eSchmerz\u003c/em\u003e 2022;36:109-120.\u003c/li\u003e\n\u003cli\u003eBasler H-D. The Marburg questionnaire on habitual health findings \u0026ndash; a study on patients with chronic pain. \u003cem\u003eSchmerz\u003c/em\u003e 1999;13:385-391.\u003c/li\u003e\n\u003cli\u003eNilges P, Essau C. Depression, anxiety and stress scales: DASS- a screening procedure not only for pain patients. \u003cem\u003eSchmerz\u003c/em\u003e 2015;29:649-657.\u003c/li\u003e\n\u003cli\u003eRaschner C, Lembert S, Platzer HP, et al. S3-Check- evaluation and generation of normal values of a test for balance ability and postural stability. \u003cem\u003eSportverletz Sportschaden\u003c/em\u003e 2008;22:100-105.\u003c/li\u003e\n\u003cli\u003eTan H, Aziz A, Teh K, et al. Reliability of the stair-climb test (SCT) of cardiorespiratory fitness. \u003cem\u003eAdv Exerc Sports Physiol\u003c/em\u003e 2004;10:77-83.\u003c/li\u003e\n\u003cli\u003eBennell K, Dobson F, Hinman R. Measures of physical performance assessments: Self-Paced Walk Test (SPWT), Stair Climb Test (SCT), Six-Minute Walk Test (6MWT), Chair Stand Test (CST), Timed Up \u0026amp; Go (TUG), Sock Test, Lift and Carry Test (LCT), and Car Task. \u003cem\u003eArthritis Care Res (Hoboken)\u003c/em\u003e 2011;63 Suppl 11:S350-370.\u003c/li\u003e\n\u003cli\u003eSchellenberg KL, Lang JM, Chan KM, et al. A clinical tool for office assessment of lumbar spine stabilization endurance: prone and supine bridge maneuvers. \u003cem\u003eAm J Phys Med Rehabil\u003c/em\u003e 2007;86:380-386.\u003c/li\u003e\n\u003cli\u003eBohannon RW, Steffl M, Glenney SS, et al. The prone bridge test: performance, validity, and reliability among older and younger adults. \u003cem\u003eJ Bodyw Mov Ther\u003c/em\u003e 2018;22:385-389.\u003c/li\u003e\n\u003cli\u003eDurall CJ, Greene PF, Kernozek TW. A comparison of two isometric tests of trunk flexor endurance. \u003cem\u003eJ Strength Cond Res\u003c/em\u003e 2012;26:1939-1944.\u003c/li\u003e\n\u003cli\u003eCohen J. Statistical power analysis for the behavioural sciences. 2nd ed. New York, NY: Routledge; 1988.\u003c/li\u003e\n\u003cli\u003eGerdle B, \u0026Aring;kerblom S, Brodda Jansen G, et al. Who benefits from multimodal rehabilitation - an exploration of pain, psychological distress, and life impacts in over 35,000 chronic pain patients identified in the Swedish Quality Registry for Pain Rehabilitation. \u003cem\u003eJ Pain Res\u003c/em\u003e 2019;12:891-908.\u003c/li\u003e\n\u003cli\u003ePietil\u0026auml; Holmner E, Fahlstrom M, Nordstrom A. The effects of interdisciplinary team assessment and a rehabilitation program for patients with chronic pain. \u003cem\u003eAm J Phys Med Rehabil\u003c/em\u003e 2013;92:77-83.\u003c/li\u003e\n\u003cli\u003eP\u0026ouml;hlmann K, Tonhauser T, Joraschky P, et al. The Dachau multidisciplinary treatment program for chronic pain. Efficacy data of a diagnosis-independent multidisciplinary treatment program for back pain and other types of chronic pain. \u003cem\u003eSchmerz\u003c/em\u003e 2009;23:40-46.\u003c/li\u003e\n\u003cli\u003ePreis MA, Vogtle E, Dreyer N, et al. Long-term outcomes of a multimodal day-clinic treatment for chronic pain under the conditions of routine care. \u003cem\u003ePain Res Manag\u003c/em\u003e 2018;2018:9472104.\u003c/li\u003e\n\u003cli\u003eRingqvist \u0026Aring;, Dragioti E, Bj\u0026ouml;rk M, et al. Moderate and stable pain reductions as a result of interdisciplinary pain rehabilitation- a cohort study from the swedish quality registry for pain rehabilitation (SQRP). \u003cem\u003eJ Clin Med\u003c/em\u003e 2019;8.\u003c/li\u003e\n\u003cli\u003eRitchie CS, Patel K, Boscardin J, et al. Impact of persistent pain on function, cognition, and well-being of older adults. \u003cem\u003eJ Am Geriatr Soc\u003c/em\u003e 2023;71:26-35.\u003c/li\u003e\n\u003cli\u003eTseli E, Boersma K, Stalnacke BM, et al. Prognostic factors for physical functioning after multidisciplinary rehabilitation in patients with chronic musculoskeletal pain: a systematic review and meta-analysis. \u003cem\u003eClin J Pain\u003c/em\u003e 2019;35:148-173.\u003c/li\u003e\n\u003cli\u003eKarayannis NV, Sturgeon JA, Chih-Kao M, et al. Pain interference and physical function demonstrate poor longitudinal association in people living with pain: a PROMIS investigation. \u003cem\u003ePain\u003c/em\u003e 2017;158:1063-1068.\u003c/li\u003e\n\u003cli\u003eGreenberg J, Mace RA, Popok PJ, et al. Psychosocial correlates of objective, performance-based, and patient-reported physical function among patients with heterogeneous chronic pain. \u003cem\u003eJ Pain Res\u003c/em\u003e 2020;13:2255-2265.\u003c/li\u003e\n\u003cli\u003eBendix AF, Bendix T, H\u0026aelig;strup C. Can it be predicted which patients with chronic low back pain should be offered tertiary rehabilitation in a functional restoration program? A search for demographic, socioeconomic, and physical predictors. \u003cem\u003eSpine\u003c/em\u003e 1998;23:1775-1784.\u003c/li\u003e\n\u003cli\u003eSteenstra IA, Munhall C, Irvin E, et al. Systematic review of prognostic factors for return to work in workers with sub acute and chronic low back pain. \u003cem\u003eJ Occup Rehabil\u003c/em\u003e 2017;27:369-381.\u003c/li\u003e\n\u003cli\u003evan der Hulst M, Vollenbroek-Hutten MM, Ijzerman MJ. A systematic review of sociodemographic, physical, and psychological predictors of multidisciplinary rehabilitation-or, back school treatment outcome in patients with chronic low back pain. \u003cem\u003eSpine\u003c/em\u003e 2005;30:813-825.\u003c/li\u003e\n\u003cli\u003eKroenke K, Wu J, Bair MJ, et al. Reciprocal relationship between pain and depression: a 12-month longitudinal analysis in primary care. \u003cem\u003eJ Pain\u003c/em\u003e 2011;12:964-973.\u003c/li\u003e\n\u003cli\u003eTeh CF, Zaslavsky AM, Reynolds CF, 3rd, et al. Effect of depression treatment on chronic pain outcomes. \u003cem\u003ePsychosom Med\u003c/em\u003e 2010;72:61-67.\u003c/li\u003e\n\u003cli\u003eParkitny L, McAuley JH, Walton D, et al. Rasch analysis supports the use of the depression, anxiety, and stress scales to measure mood in groups but not in individuals with chronic low back pain. \u003cem\u003eJ Clin Epidemiol\u003c/em\u003e 2012;65:189-198.\u003c/li\u003e\n\u003cli\u003eScascighini L, Toma V, Dober-Spielmann S et al. Multidisciplinary treatment for chronic pain: a systematic review of interventions and outcomes. \u003cem\u003eRheumatology\u003c/em\u003e 2008;47\u003cem\u003e:\u003c/em\u003e670-678.\u003c/li\u003e\n\u003cli\u003eAbberger B, Kieselbach K. Rasch analysis of the Depression, Anxiety, and Stress Scale in patients with chronic pain. \u003cem\u003eJ Psychosom Res\u003c/em\u003e 2024;178:111597.\u003c/li\u003e\n\u003cli\u003eAste JA. Chronic pain and stigma. A literature review [Doctoral dissertation]. Ann Arbour, MI: Union Institute and University; 2016.\u003c/li\u003e\n\u003cli\u003eRolli Salath\u0026eacute; C, Elfering A. A health- and resource-oriented perspective on NSLBP. \u003cem\u003eISRN Pain\u003c/em\u003e 2013;2013:640690.\u003c/li\u003e\n\u003cli\u003eWilhelm LO, Lederle N, Diering L-E, et al. Linking physical activity to workers\u0026rsquo; low back pain, back health, and theory-based psychological variables: study protocol of the workHealth intensive longitudinal observational study. BMC Public Health 2025;25:995.\u003c/li\u003e\n\u003cli\u003eBartley EJ, Ofri BL, Vasilopoulos T, et al. (2024). Promoting a foundation of resilience in older adults: pilot trial of a strengths-based positive psychology intervention for chronic low back pain. Health Psychol Behav Med, 2024;12:2434711.\u003c/li\u003e\n\u003cli\u003eEich W, Diezemann-Prossdorf A, Hasenbring M, et al. [Psychosocial factors in pain and pain management: a statement]. \u003cem\u003eSchmerz\u003c/em\u003e 2023;37:159-167.\u003c/li\u003e\n\u003cli\u003eKaiser U, Nagel B, Petzke F, et al. [Prevention of chronic pain in the German healthcare system: current state and perspective]. \u003cem\u003eSchmerz\u003c/em\u003e 2021;35:45-52.\u003c/li\u003e\n\u003cli\u003eFleig L, Radtke T, Dombrowski S. Understanding multiple health behaviours. In \u003cem\u003eThe Routledge International Handbook of Health Psychology\u003c/em\u003e (pp. 222-241). New York, NY: Routledge; 2025. \u003c/li\u003e\n\u003cli\u003eL\u0026oacute;pez-Mart\u0026iacute;nez AE, Esteve-Zarazaga R, Ram\u0026iacute;rez-Maestre C. Perceived social support and coping responses are independent variables explaining pain adjustment among chronic pain patients. \u003cem\u003eJ Pain\u003c/em\u003e 2008;9:373-379.\u003c/li\u003e\n\u003cli\u003eMartinez-Calderon J, Zamora-Campos C, Navarro-Ledesma S, et al. The role of self-efficacy on the prognosis of chronic musculoskeletal pain: a systematic review. \u003cem\u003eJ Pain\u003c/em\u003e 2018;19:10-34.\u003c/li\u003e\n\u003cli\u003evan der Hulst M, Vollenbroek-Hutten MM, Groothuis-Oudshoorn KG, et al. Multidisciplinary rehabilitation treatment of patients with chronic low back pain: a prognostic model for its outcome. \u003cem\u003eClin J Pain\u003c/em\u003e 2008;24:421-430.\u003c/li\u003e\n\u003cli\u003eFurrer A, Michel G, Terrill AL, et al. Modeling subjective well-being in individuals with chronic pain and a physical disability: the role of pain control and pain catastrophizing. \u003cem\u003eDisabil Rehabil\u003c/em\u003e 2019;41:498-507.\u003c/li\u003e\n\u003cli\u003eWarner LM, Schwarzer R, Schuz B, et al. Health-specific optimism mediates between objective and perceived physical functioning in older adults. \u003cem\u003eJ Behav Med\u003c/em\u003e 2012;35:400-406.\u003c/li\u003e\n\u003cli\u003eFields HL. How expectations influence pain. \u003cem\u003ePain\u003c/em\u003e 2018;159 Suppl 1:S3-S10.\u003c/li\u003e\n\u003cli\u003eArtus M, van der Windt DA, Jordan KP, et al. Low back pain symptoms show a similar pattern of improvement following a wide range of primary care treatments: a systematic review of randomized clinical trials. \u003cem\u003eRheumatology\u003c/em\u003e 2010;49:2346-2356.\u003c/li\u003e\n\u003cli\u003eL\u0026oslash;nn JH, Glomsr\u0026oslash;d B, Soukup MG, et al. Active back school: prophylactic management for low back pain. A randomized, controlled, 1-year follow-up study. \u003cem\u003eSpine\u003c/em\u003e 1999;24:865-871.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Table 2","content":"\u003cp\u003eTable 2 is available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Charité - University Medicine Berlin","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"interdisciplinary multimodal pain therapy, chronic pain, physical function, well-being, physical health","lastPublishedDoi":"10.21203/rs.3.rs-6865142/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6865142/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjectives\u003c/h2\u003e\u003cp\u003eThe aim of this single-arm pre-post intervention study was to evaluate an interdisciplinary multimodal pain therapy (IMPT) in a day clinic for people with chronic musculoskeletal pain under routine care conditions. Primary objectives included assessing changes in pain intensity and pain-related disability and examining theory- and evidence-based correlates of these treatment outcomes, such as parameters of mental and physical health.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eA cohort of \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;308 patients underwent a four-week IMPT, which included exercise, manual therapy, and cognitive behavioural therapy. Pain intensity and disability (CPG), well-being (FW-7), mental and physical health (VR-12), depressive symptoms, anxiety, and stress (DASS) were assessed using self-report questionnaires before and six months after the IMPT was completed. Physical function was assessed using performance-based measures including the stair climb test, the MFT-S3-Check and the prone bridge test before and after treatment. Data were analysed using dependent samples \u003cem\u003et\u003c/em\u003e-tests and multiple linear regressions.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eSix months post-treatment, patients showed reductions in pain intensity (\u003cem\u003ed\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.95) and disability (\u003cem\u003ed\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.75). Reductions in depression, anxiety, and stress,well-being, mental and physical health, and physical function were also observed, with small to large effect sizes. Regression analysis showed that improvements in self-reported well-being and physical health were associated with changes in pain. However, this was not the case for changes in performance-based physical function or changes psychological risk factors (i.e., depressive symptoms, anxiety, stress).\u003c/p\u003e\u003ch2\u003eDiscussion\u003c/h2\u003e\u003cp\u003eThe results indicate that individuals with chronic pain experienced sustained benefits from IMPT for up to six months following treatment completon. The findings highlight the role of changes in self-reported well-being and physical health in reducing pain. The investigation of psychosocial and behavioural mechanisms is an important avenue for future studies.\u003c/p\u003e","manuscriptTitle":"Interdisciplinary Multimodal Pain Therapy for chronic musculoskeletal pain in a day clinic setting: Examining patient-reported and performance-based correlates of treatment outcomes","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-30 13:58:05","doi":"10.21203/rs.3.rs-6865142/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"6f94d39d-327e-4cbc-a68f-7a8cbdc5994e","owner":[],"postedDate":"July 30th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-07-30T13:58:05+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-30 13:58:05","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6865142","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6865142","identity":"rs-6865142","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}