Ph ysioth erapy Theory a n d Pra ctice ( 2001 ) 17 , 77 –95
Ó 2001 Taylor & Francis
A comparative outcome study of body awareness
therapy, feldenkrais, and conventional physiotherapy
for patients with nonspeci c musculoskeletal
disorders: changes in psychological symptoms, pain,
and self-image
Eva-Britt Malmgren-Olsson, Bengt-Ake Armelius, and Kerstin
Armelius
Patients with nonspeciŽ c musculoskeletal disorders are often remitted for
physiotherapy treatment in primary care. The rehabilitation effects for this patient
group are generally poor and many of the treatment methods used have not been
scientiŽ cally evaluated. The purpose of this study is to compare treatment effects
of Body Awareness Therapy, Feldenkrais, and conventional individual treatment
with respect to changes in psychological distress, pain, and self-image in patients
with nonspeciŽ c musculoskeletal disorders. A total of 78 patients, 64 females and
14 males, with non speciŽ c musculoskeletal disorders were recruited consecutively
to the different treatment groups in a quasiexperimental design. The patients were
measured three times during the study period: before the interventions, after six
months, and after on e year. The results showed signiŽ cant positive changes over
time in all three treatment groups with regard to reduced psychological distress,
pain, and improved negative self-image. There were few signiŽ cant differences
among the groups but effect-size analysis indicated that the group treatments using
Body Awareness Therapy and Feldenkrais might be more effective than
conventional treatment.
INTRODUCTION
Patients with chronic musculoskeletal pain
disorders ( MSD) without diagnosed organic
causes are a large group that are often
remitted for physiotherapeutic treatment in
primary care. Especially pain-related syndromes
such as myalgia and Ž brositis have increased
Eva-Britt Malmgren-Olsson, Lecturer, Department of Community Medicine and Rehabilitation,
Umea University, S-901 87 Umea, Sweden. (Correspondence to this address).
E-mail: [email protected] e
Bengt -Ake Armelius, Professor, Department of Psychology, Umea University, Umea, Sweden.
Kerstin Armelius, Associate Professor, Department of Psychology, Umea University, Umea,
Sweden.
Accepted for publication April 2001.
78
E.-B. MALMGREN-OLSSON ET AL.
during the last decade ( Andersson, 1999) .
Despite the physiotherapist’s long tradition of
working with different treatment methods for
this patient group the rehabilitation effects
are generally poor ( Carlsson, 1993; Feine
and Lund, 1997 ) . In two reviews on the
evaluation of physiotherapeutic interventions,
the conclusion was that treatments that focus
only on pain relief or improving physical
function are not effective for chronic pain
disorders ( SBU, 1999a, 1999b ) . In these reviews
it was also shown that scientiŽ c support for
many of the conventional treatment methods
was limited, especially for neck disorders, and
there was a lack of controlled studies.
In two recent Swedish reports on musculoskeletal disorders published by the Swedish
Council on Technology Assessment in Health
Care ( SBU) , the authors strongly emphasise the need to integrate a psychological
and a social perspective early in the assessment and treatment of musculoskeletal problems ( SBU, 2000a, 2000b ) . It was found
that psychological factors such as psychological distress —especially anxiety and depression — and coping strategies are more important predictors than biological factors in the
development from acute to more chronic
musculoskeletal conditions. In one study
Burton, Tillotson, Main, and Hollis ( 1995 )
showed that the initial psychological state had
more in uence on pain development than
conventional clinical information. As nonspeciŽ c musculoskeletal disorders are regarded as
a multi-dimensional problem there is a need for
more broad therapeutic treatment approaches
in the rehabilitation of these patients ( Laerum
et al, 1998 ) . A change of strategy from a
biomedical perspective to a biopsychosocial
perspective is advocated and it is recommended
that the health care system should be based on
early treatment interventions in primary care
( Waddell, 1996) .
During the last 15 years, new treatment
models have developed in physiotherapy built
on theories of body and mind in which the
intention is to integrate bodily experiences
with psychological insights and cognitive understanding ( Mattson, 1998; Rosberg, 2000) .
One of the treatment models, Body Awareness Therapy ( BAT) , has been developed
by Roxendal ( Roxendal, 1985 ) in Swedish
psychiatric physiotherapy and is now used by
physiotherapists in primary care for patients
with different pain problems ( Lind, 1993 ) .
In several studies BAT has been considered
a useful intervention for patients with different
pain conditions as well as for patients with
personality disorders in psychiatric care ( Friis
et al, 1989; Mattsson et al, 1998; KlingbergOlsson, Lundgren, and Lindstr öm, 2000 ) .
However, these studies evaluated a single
treatment group before and after an intervention and therefore comparative studies
including other treatment approaches are
lacking.
Another treatment model that has attracted
many physiotherapists is the Feldenkrais
method ( FK) which is a pedagogic method,
called somatic education, that emphasis the
learning process of the individual’s own experience and conciousness of body and movement. The method is based on the work of
Moshe Feldenkrais who devoted a large part
of his life to the development of what he
called movement education and the exploration of the relationship between self-image
and motor expression ( Feldenkrais, 1972,
1977, 1985 ) . The principal thinking is that
improvements of body behaviour would lead to
corresponding changes in mind. The method
relies on neurophysiological principles aimed
at changing unfavourable ingrained movement patterns in the individual that cause
pain and dysfunction and instead promoting
free and harmonious ways of moving. The
Feldenkrais method is spread worldwide and
is extensively used in the United States,
Australia, and Germany ( Wildman, 1990;
Bühler, 1993 ) . According to two review articles, the Feldenkrais research relies heavily
on case reports and observations and there
is no clear evidence regarding its effectiveness ( Ellis, 1995; Ives and Shelley, 1998 ) .
Recently one randomised controlled study on
patients with neck-shoulder complaints has
been published in which Feldenkrais was found
to have signiŽ cantly better treatment results
COMPARATIVE STUDY OF NONSPECIFIC MSD PATIENTS
compared to a group-based physiotherapy intervention ( Lundblad, Elert, and Gerdle, 1999 ) .
In the present study BAT and FK are
compared with conventional physiotherapy
( Treatment as Usual [ TAU] ) for patients with
musculoskeletal disorders, and these different
treatment approaches are evaluated from both
physiological and psychological perspectives.
In a previous study, the initial status and
the relation among different health problems
of this patient group have been presented
( Malmgren-Olsson and Armelius, in press ) . The
present paper focuses on outcomes in terms
of psychological and pain experiences. Psychological outcomes may be of many different
kinds. Perhaps the most relevant psychological variables concern the patient’s experience
of well-being or distress, since this is what
brings patients to treatment. For chronic pain
patients the experiences of somatic distress is
of primary importance, but such experiences
are usually accompanied by other psychological symptoms ( e.g., depression or anxiety)
( Dyrehag et al, 1998) . Whether pain causes
psychological distress or vice versa seems to be
an open question. Thus, it has been shown
that chronic stress may lead to biochemical
imbalance ( e.g., it has been found that disturbances in the neuroendocrinological production in the form of low cortisol levels may
lead to psychological distress ) ( Preussner, Hellhammar, and Kirschbaum, 1999; Rosmond
and Björntorp, 2000) . In contrast, Von Korff
and Saunders ( 1996 ) concluded that there is
no indication that, for example, depression
emerges simply as a function of chronicity.
They suggest that chronic pain dysfunction
may represent a failure to restore normal
functioning rather than a progressive deterioration as pain changes from acute to
chronic.
It has also been shown that high levels
of symptoms are related to a negative selfimage ( Öhman and Armelius, 1990) . Within
interpersonal psychology a person’s self-image
is considered to be a result of early important
relationships where an individual learns to
treat him or herself as signiŽ cant others have
treated him or her ( Sullivan, 1953; Benjamin,
79
1974 ) . The basic idea is that if primary goals
of achieving love and acceptance and a sense
of self-worth have not been met due to
shortcomings in early parenting the results
will be adult interpersonal and intrapsychic
problems. Traditional psychiatric symptoms
such as depression, anxiety, and somatization
are often embedded in interpersonal patterns.
In this study the interest is to focus on
both psychological symptoms and self-image
as outcome measures since they might play an
important role in the rehabilitation of pain
disorders. Subjective experiences of symptoms
and a person’s self-image might be expected
to show different susceptibility to change.
Symptoms are often more sensitive to changes
as a result of treatments, while self-image might
be thought of as a more stable psychological
entity that is more difŽ cult to change.
The purpose of the present study is to
compare the effects of three different treatment
approaches —BAS, FK, and TAU — in patients
with nonspeciŽ c musculoskeletal disorders on
change in psychological symptoms, pain, and
self-image.
MATERIAL AND METHODS
Inclusion of patients and
procedure
Patients with different pain syndromes that
were diagnosed as nonspeciŽ c musculoskeletal
disorders were recruited consecutively under a
concentrated period of nine months to the
different treatment models in three health
care districts in Sweden. The BAT treatment
model and the TAU group were carried out
in a district in the northern part of Sweden
and the FK treatment model was used in
two districts in the southern part of Sweden.
The districts were chosen according to where
BAT and FK were extensively used and where
interested physiotherapists and Feldenkrais
pedagogues were willing to participate in the
study. The design of the study was thus a quasiexperimental controlled comparative outcome
study ( Cook and Campell, 1979 ) . The aim was
80
E.-B. MALMGREN-OLSSON ET AL.
to study 30 patients in each treatment model
since the expected effect size of psychosocial
treatments can be estimated to be around 0.80
( Bergin and GarŽ eld, 1994) . The number of
patients is a compromise between the desire
to be able to detect true differences among
groups and the clinical problems of recruiting
patients within an acceptable time span. A
power analysis suggested that the number of
subjects was sufŽ cient to detect a true difference
in change scores comparable to an effect size of
around 0.7, although differences between active
treatments might be too small to be detected
with this sample size.
Information about the study and selection criteria of the patients was given both
orally and in written form to the involved
physicians, physiotherapists, and Feldenkrais
pedagogues in the three districts. The inclusion
criteria were patients, born in Scandinavia, with
prolonged ( more than three months ) nonspeciŽ c musculoskeletal disorders. Excluded were
patients with musculoskeletal disorders with
a clear organic cause due to obvious tissue
damage or herniated discs, diagnosed neurological, rheumatic, or metabolic diseases, or
diagnosed Ž bromyalgia.
A total of 78 patients ( 64 women and
14 men ) with nonspeciŽ c musculoskeletal
disorders had been examined and referred
to physiotherapy treatment by the informed
physicians in primary care and were found
to fulŽ ll the inclusion criteria. The patients
were not diagnosed according to any formal
diagnostic system since this was not usually
done in primary care in Sweden at the
time of the study. Instead the physicians
used different symptom descriptions in their
referrals to the physiotherapists. Although
there is no clear consensus about the term
nonspeciŽ c musculoskeletal disorders it is
familiar to health professionals in primary
care and usually considered to belong to the
group ‘‘chronic pain disorders.’’ In the present
study it includes many different vague pain
syndromes without any known organic cause
where psychological and social factors probably
play an important role for the genesis and the
duration of the problems. The prevalence of
the initially reported symptoms and complaints
of the patient group is presented in Table 1.
The most frequent symptoms were fatigue
together with neck/shoulder pain, back pain,
and headache. Most patients had symptoms
from more than one body region, 27% had
more general ache symptoms, and a similar
proportion had their pain problems for more
than ten years. Only 14% had their problems
less than one year. Many of the symptoms
may be considered to be of a psychosomatic
nature.
Due to practical realities, the recruitment
of patients had to cease when there were
26 patients in each model. All patients had
provided signed informed content to participate in the study. Outcome measurements were
made three times —before treatment, after six
months, and at one year —by the Ž rst author of
this study who did the measurements with all
patients individually at the health care centre
where the patients belonged.
Seven patients dropped out during the
treatment period: two men and two women
from the FK group and one man and two
women from the BAT. The reasons for
dropping out in Ž ve cases was lack of motivation
and, in two cases, lack of time. These patients
didn’t differ from the rest of the patients
according to background variables. Seventy-one
Table 1
The prevalence of initial symptoms in the
total patient group
Symptoms
n
%
Fatigue
Neck/shoulder pain
Back pain
Headache
Sleep disturbances
Concentration problems
Stomach trouble
Joint ache
Anxiety
Maxillary joint disorders
Sadness
Dizziness
Memory problems
Throat symptoms
Breathing symptoms
Tinnitus
Heart symptoms
75
63
52
41
27
27
26
25
25
21
20
13
15
10
9
4
4
99
83
67
53
36
36
34
34
33
27
26
17
20
13
12
5
5
COMPARATIVE STUDY OF NONSPECIFIC MSD PATIENTS
patients participated during the whole study
consisting of 23 patients in the BAT group, 22
patients in the FK group, and 26 patients in the
TAU group.
Intervention groups
Both the Body Awareness Therapy Training and
Feldenkrais groups were contracted to consist
of 20 sessions, most of them group sessions, but
a few individual treatments, too. This number
of sessions was based on the results from a
pilot study that showed that 10 group sessions
were too few to be effective for patients with
chronic pain disorders ( Malmgren-Olsson and
Lampa, 1997 ) . In order to assure consistent use
of a treatment model the group leaders within
each of the BAT and FK methods discussed
and planned the content in their treatment
model before the intervention started. In the
TAU group there was no contract. Instead,
each physiotherapist was free to decide how
many sessions he or she thought were necessary
for the patient and the physiotherapist was
allowed to Ž nish the treatment period when
he or she thought it was most appropriate.
These physiotherapists also were instructed to
perform what they thought would be the most
relevant treatment in each case. Separating the
men and women into different groups in both
BAT and FK was recommended by experienced
clinicians who had found that it was often more
difŽ cult for patients to talk about individual
problems in mixed groups.
Body Awareness Therapy group
The 23 patients in the BAT treatment model
consisted of three groups: two groups of
women, numbering nine and eight, respectively, and one group of six men. Three
different physiotherapists with much experience and education in the method of BAT
had one group each. The BAT intervention
consisted of 17 group sessions and 3 individual
sessions. Each session lasted 90 minutes, twice
a week at Ž rst and once a week later on. The
intervention period was three to four months.
The movements in BAT consisted of simple
81
basic movements of daily living such as lying,
sitting, standing, and walking used to normalize
postural control and coordination, breathing,
and muscular tension. The physiotherapists
recommended that the patients do these movements at home. In BAT the concept of body ego
is central and means that the experiences of
the body are a part of the identity. The method
uses other central concepts such as grounding,
stability in the centre line, centering, breathing,
and  ow in the body. BAT also included special
massage techniques that the patients performed
on each other during pair exercises. During the
individual sessions as well as during the group
sessions, the patients had the opportunity to
talk about their experiences of the movements
and to re ect on the interaction between pain
and environmental factors.
Feldenkrais group
Similarly to the BAT group the 22 patients
in the FK group consisted of three groups:
two groups of women, numbering ten and
eight, respectively, and one group of four
men. Two female Feldenkrais pedagogues
led these groups. One practitioner had two
groups, the other one group. The treatment
intervention consisted of 15 group treatment
sessions, called lessons, and Ž ve individual
sessions. The group part of the intervention was
labelled Awareness through Movement ( ATM)
lessons and consisted of speciŽ c verbally
directed movements aimed at increasing the
sensorimotor awareness and coordination of
different body parts organised around a
functional theme. During the lessons, time for
discussion and re ections on the experiences
of the movements was given. The individual
lessons, labelled Functional Intergration ( FI) ,
were aimed at focusing on each patient’s
individual functional problem by using mostly
nonverbal guiding techniques. At the end of
the intervention the patients also received
two audio cassettes containing some of the
exercises used during the ATM lessons and
also a written sheet detailing most of the
exercises.
82
E.-B. MALMGREN-OLSSON ET AL.
Treatment as Usual Group
The 26 patients in this group, 25 women
and one man, were treated individually by
a total of 13 physiotherapists with much
experience with chronic pain patients; eight
physiotherapists were working in six different
primary health care areas, and Ž ve were
working in four different private practices.
After the intervention it was shown that the
number of treatments that the patients had
received in this group differed largely, with
a distribution of from 5 – 45 treatments with
a median of 12 treatments at the 6-months
follow up. In the TAU group 14 patients
continued with treatments to the second followup at one year, and at that measurement
time, the total median of treatments was 20
( range 5 – 90 ) . It was found that massage,
hot-pack, acupuncture, and transcutaneous
electrical nerve stimulation ( TENS) were the
treatments most often used, in combination
with other methods like mobilisation and
exercise training as well as information and
advice about preventive strategies.
Comparison groups
The comparison group for the Symptom CheckList-90 ( SCL-90) consisted of 51 subjects ( 28
males and 17 females ) with a mean age of 27.8
years ( range 21 –42) and, for the Structural
Analysis of Social Behaviour ( SASB ) , 52 subjects
( 24 males and 28 females ) with a mean age of
33 years ( range 20 –56) . All subjects in the
comparison groups were either working or
studying and none was at the time of testing
a psychiatric patient or had any known somatic
diseases.
Psychological distress
The SCL-90 is a 90-item self-report symptom
inventory designed to re ect the psychological
symptom patterns of patients on a number
of different subscales ( Derogatis and Cleary,
1977 ) The degree of distress is measured on
a 5-point scale, ranging from 0 ( not at all ) to
4 ( extremely) . The check-list consists of the
following ten primary symptom dimensions:
somatization, obsessive-compulsive disorders,
interpersonal sensitivity, depression, anxiety,
hostility, phobic anxiety, paranoid ideation,
psychoticism, and an additional scale. The
instrument has three global indices of distress.
The mean of all 90 items constitutes the Global
Severity Index ( GSI) which is considered to be
the best single indicator of the current level of
distress. The Personality Severity Index ( PSI)
is an index for personality disorders based on
the mean score of the subscales’ interpersonal
sensitivity, hostility, and paranoid ideation
( Karterud et al, 1995) . The State Symptom
Index ( SSI) is an index of mood-related
symptoms consisting of the mean of anxiety,
depression, obsessive-compulsive, and somatic
symptoms ) . SCL-90 has been widely used in
different patient groups both as a screening
instrument of psychological distress and for
assessment of treatment outcome ( Bergin and
GarŽ eld, 1994; Derogatis and Cleary, 1977;
Andersen and Johansson, 1998 ) . The SCL-90
has high internal consistency and high testretest reliability ( Derogathis and Clearly, 1977 ) .
In the present study we use the three global
indices —GSI, PSI, SSI —in order to estimate
overall symptoms and the subscales of anxiety,
depression, and somatization to access speciŽ c
symptom dimensions.
Pain
The Swedish version ( Bergstr öm et al, 1998 )
of the West Haven Yale Multidimensional Pain
Inventory ( MPI) was used to assess physical and
psychosocial aspects of chronic pain ( Kerns,
Turk, and Rudy, 1985) . The MPI instrument
is made up of three sections with a total of
nine empirically derived scales. Part I consists
of Ž ve scales designed to assess ( 1 ) pain severity,
( 2) perception of how pain interferes with
the patient’s life, ( 3) perceived life control,
( 4) affective distress, and ( 5 ) the amount of
support the patient receives from signiŽ cant
others. Part II assesses the frequency of a range
of behavioral responses by signiŽ cant others to
the patient’s communications of pain. Part III
is comprised of a list of 18 common activities
COMPARATIVE STUDY OF NONSPECIFIC MSD PATIENTS
that the patient rates in terms of the frequency
with which these activities are performed. The
present study is restricted to Part I of MPI.
The Pain Severity ( PS) scale consists of
3 items that assess the perceived severity
of pain ( pain right now, average pain past
week, suffering due to pain ) by Likert-type
scales where 0 no pain/suffering and 6
extreme pain/suffering. A high mean subscale
score indicates high perceived pain severity.
The Pain Interference ( PI) scale includes
11 items that assess the extent to which
chronic pain interferes with life. The Life
Control ( LC) scale consists of four items that
assess the degree to which patients perceive
they have control over pain and more general
control over life problems and the ability
to deal with stress during the past week.
The Affective Distress ( AD) scale includes 3
items that assess mood, level of anxiety, and
irritation during the past week ( 0 very good
mood/not at all anxious/irritated, 6 very
bad mood/extremely anxious/irritated ) . The
Support ( S) scale consists of three items that
assess the perceived support from signiŽ cant
others ( 0 not at all, 6 extremely high ) .
A mean score is computed for each scale.
83
The Swedish version of the MPI has shown
satisfactory internal consistency and test-retest
reliability ( Bergstr öm et al, 1998 )
Self-image
As a measure of self-image, the introject
version of the Structural Analysis of Social
behaviour ( SASB) , developed by Benjamin
( 1974 ) , was used. The SASB model consists
of two basic dimensions: afŽ liation ( love-hate )
and interdependence ( spontaneity-control ) . In
the SASB model the two basic dimensions
are combined in a circum ex model and
operationalized as 36 items in a questionnaire,
where the participants are asked to rate on a
scale between 0 and 100 how well the statement
describes the person. In the cluster version
of the model the 36 items are summarised
into eight clusters describing how an individual
treats him or herself ( Fig. 1 ) . SASB has high
test-retest reliability and internal consistency
( Benjamin, 1974) . In the present study the
mean ratings of the positive clusters 2, 3,
and 4 ( accept, love, and nourish self ) were
used as a measure of a positive self-image and
the mean of the negative clusters 6, 7, and
Fig. 1 Self-image (SASB). The cluster version
84
E.-B. MALMGREN-OLSSON ET AL.
8 ( blame, reject, and ignore self ) were used
as a measure of negative self-image. cluster 1
expresses the degree of spontaneity of the self
and cluster 5 can be seen as the opposite to
this cluster and measures self-control. A normal
of self-image according to the SASB model is
characterized by high values on the positive
clusters and low values on the negative clusters
and a balance between a spontaneous self and
a controlling self.
Statistical Analysis
To analyse if background factors and symptoms
and self-image differed among the three
treatment groups before treatment one-way
analysis of variance ( ANOVA) was used for
parametric variables and chi-square was used
for nonparametric variables. A signiŽ cance
level of p 0 05 was used if nothing else is
speciŽ ed. In the one-way ANOVA of initial
psychological symptoms and self-image, the
comparison groups also were included. In
order to study the changes over time in
the different groups for SCL-90 and SASB a
two-way ANOVA was used —3 groups ( BAT,
FK, TAU) 3 times ( before treatment, after
6 months, after one year ) with repeated
measurements on time. Post-hoc analyses were
made according to Bonferroni. In this way too
many separate signiŽ cance tests were avoided.
Finally, Pearson’s correlation coefŽ cients were
used to study relations among initial status,
amount of treatment, and outcome.
Effect-size ( ES) measurements were calculated to describe overall treatment effects
( Rosenthal and Rosnow, 1991 ) . This is a standardised measure of change used in treatment
research and in meta-analysis of treatment
outcome ( Cohen, 1988; Rosenthal and Rosnow,
1991; Bergin and GarŽ eld, 1994) . The ES
can be computed in different ways but here
it was calculated as the difference between
before treatment ( T1) and after one year ( T3 ) ,
divided by the combined standard deviation for
the total patient group before measurement
( ES T1 T3 SD1 for the total group ) . ES
values are always calculated so that a positive
change gets a positive value. One advantage
with the use of ES values is that there are established criteria for what is considered to be a
large or a small change of outcome. The most
common criteria are based on Cohen’s ( 1988 )
work that speciŽ es that values under 0.2 are
considered as no effect, values between 0.2 and
0.5 as a small effect, values between 0.5 and 0.8
as a medium effect, and values above 0.8 are
regarded as a large effect.
RESULTS
Background characteristics
There were no signiŽ cant differences between
the Body Awareness group ( BAT) , the
Feldenkrais group ( FK) and the Treatment as
Usual group ( TAU ) concerning background
factors except for the fact that there was only
one man in the TAU group ( see Table 2 ) .
Psychological symptoms
In Table 3 mean values and the standard deviations on the global index and the subscales
of the SCL-90 are presented for each treatment group and for each measurement time
together with the values for the comparison
group. According to one-way ANOVA, when all
four groups were compared there were significant differences among the initial values in
the three treatment groups and the normal
comparison group for the GSI ( p
01) and
the SSI ( p
01 ) . The TAU group was, however,
very close to the normal comparison group on
GSI ( p
06 ) . On the PSI, there were no significant differences among the four groups. When
comparing only the three treatment groups
there were no signiŽ cant differences on any
of the single dimensions of SCL-90 before
treatment.
The results of the two-way ANOVA showed
signiŽ cant improvements over time on the
three indices GSI, SSI, and PSI ( p 0 01 )
for the treatment groups. The same signiŽ cant
pattern was found on the speciŽ c scales of somatization, anxiety, and depression ( p 0 01) .
These signiŽ cant improvements were between
85
COMPARATIVE STUDY OF NONSPECIFIC MSD PATIENTS
Table 2
Comparison of background variables in the treatment groups Body Awareness Therapy (BAT), Feldenkrais (FK),
and Treatment as usual (TAU)
Variables
BAT n
n
Age (total group)
Women
Men
26
% Mean
26
19 73
7 17
Education (year)
Compulsory and secondary school
Higher education
41.8
41.1
43.7
SD
FK n
n
%
11.2 26
10.2 20 77
14.3 6 13
10.7
1.9
2.6
2.2
26
Mean
44.7
44.0
47.3
TAU n
SD
n
%
11.8 26 100
11.1 25 96
14.9 1
4
10.2
1.7
1.8
2.4
Marital status
Married/cohabitant
Divorced
Single
Widow/widower
Employment (total group)
Sick leave/pension part-time
Sick leave/pension full -time
20
2
3
1
13
6
7
77
8
11
4
50
23
27
19 73
6 23
1 4
18
7
1
69
27
4
18 69
3 12
5 19
16
6
4
62
23
15
Socioeconomic classi cation
Workers
Employees
12 46
14 54
15 58
11 42
14
12
54
46
26
Mean
SD
p-value
43.2
43.2
42.0
11.4
11.6
ns
10.4
0.9
2.1
1.5
ns
ns
ns
ns
Table 3
Mean values and standard deviations of the global indices and the subscales of SCL-90 in BAT, FK, and TAU and
a comparison group. The values of the treatment groups are measured before the intervention, at 6 months
and at one year
Variables
Before
6 months
1 year
Group
Mean
SD
Mean
SD
Mean
Global Severity Index
(GSI)
BAT
FK
TAU
Normals
0.91
0.92
0.81
0.51
0.56
0.53
0.45
0.40
0.60
0.65
0.70
0.43
0.42
0.40
0.57
0.65
0.62
0.49
0.41
0.45
Personality Severity Index
(PSI)
BAT
FK
TAU
Normals
BAT
FK
TAU
Normals
0.58
0.60
0.52
0.48
1.15
1.13
1.00
0.50
0.43
0.59
0.35
0.39
0.74
0.64
0.56
0.45
0.39
0.39
0.45
0.36
0.39
0.34
0.39
0.44
0.38
0.41
0.37
0.38
0.73
0.80
0.83
0.55
0.51
0.46
0.70
0.77
0.76
0.57
0.47
0.54
Somatization
BAT
FK
TAU
Normals
1.50
1.67
1.54
0.47
0.88
0.70
0.74
0.51
0.95
1.13
1.26
0.70
0.60
0.56
0.93
1.13
1.24
0.72
0.55
0.71
Anxiety
BAT
FK
TAU
Normals
1.15
0.85
0.85
0.56
0.96
0.73
0.67
0.59
0.65
0.57
0.71
0.64
0.57
0.46
0.60
0.52
0.55
0.56
0.51
0.52
Depression
BAT
FK
TAU
Normals
1.18
1.25
0.99
0.74
0.79
0.87
0.69
0.72
0.82
0.92
0.85
0.68
0.64
0.69
0.73
0.93
0.78
0.74
0.66
0.68
State Symptom Index
(SSI)
SD
86
E.-B. MALMGREN-OLSSON ET AL.
the initial measurement and the two following
measurements but not between the second
and the third measurement except for anxiety,
which also improved between six months and
one year. There were no signiŽ cant differences
among the three treatment groups and no
signiŽ cant interaction effect. This means that
the groups developed in the same way over time
on all variables of SCL-90. Figure 2 illustrates
the development of the total patient group on
SCL-90.
The effect-size values on the SCL-90 for the
different groups and the criteria for evaluating
the magnitude of change are illustrated in
Figure 3. Generally the BAT and FK groups
had higher ES values on all variables compared
to TAU, even if only the somatization variable
reached signiŽ cance ( p 0 03) . More exactly,
BAT reached the level of medium effect-size on
Ž ve of the six scales, FK on three scales, and
TAU did not reach medium effect-size on any
of the scales.
Pain
Mean values and standard deviations on four
subscales of MPI are shown in Table 4. The
three treatment groups showed signiŽ cant
improvements over time on the scales: pain
severity ( p 0 001 ) , pain interference, life
control, and affective disorders ( p 0 01 ) . The
only tendency to ward signiŽ cance among
group differences was on life control where FK
showed larger improvements than TAU ( p
0 07 ) . Perceived social support from signiŽ cant
others was similar in the three treatment groups
and did not change over time.
In Figure 4 the effect-size values show
that BAT achieved larger improvements on all
four scales than FK and TAU, especially on
pain severity.
Fig. 2 Mean values of the global indices GSI, PSI, SSI and the subscales somatization, depression, and anxiety
of SCL-90 of the total patient group (N 71) at three time measurements
COMPARATIVE STUDY OF NONSPECIFIC MSD PATIENTS
87
Fig. 3 Effect-size (ES) values for the global indices GSI, PSI, SSI and the subscales somatization, anxiety, and
depression in the treatment groups BAT, FK, and TAU
Table 4
Mean values and standard deviations of the subscales of MPI in BAT, FK, and TAU, measured before
the intervention, at 6 months, and at one year
Variables
Before
6 months
1 year
Group
Mean
SD
Mean
SD
Mean
Pain severity (PS)
BAT
FK
TAU
3.47
3.47
3.74
1.24
0.97
0.81
2.68
3.01
3.33
1.34
1.58
1.22
2.51
2.94
3.31
1.42
1.52
1.08
Pain interference (PI)
BAT
FK
TAU
3.18
3.25
3.10
1.48
1.40
1.00
2.80
2.66
3.05
1.43
1.66
1.04
2.55
2.86
2.95
1.49
1.39
1.14
Life control (LC)
BAT
FK
TAU
2.80
2.74
3.57
1.21
1.31
1.16
3.44
3.02
3.78
1.42
1.16
1.12
3.57
3.45
3.75
1.57
1.08
0.88
Affective distress (AD)
BAT
FK
TAU
3.12
3.00
2.63
1.52
1.70
1.28
2.48
2.15
2.33
1.47
1.48
1.23
2.30
2.33
2.44
1.69
1.16
0.97
Self-image
In Table 5 mean values and standard deviations
for both positive and negative self-images are
SD
presented for the three treatment groups and a
comparison group. Before the intervention all
three treatment groups had signiŽ cantly higher
values on the negative self-image than the
88
E.-B. MALMGREN-OLSSON ET AL.
Fig. 4 Effect-size (ES) values for the four subscales of MPI: pain severity (PS), pain interference (PI), life
control (LC), and affective distress (AD) in the treatment groups BAT, FK, and TAU
Table 5
Mean values and standard deviations of positive and negative self-image in BAT, FK, TAU and a
comparison group. The values of the treatment groups are measured before the intervention, at 6
months, and at one year
Variables
Positive
self-image
Negative
self-image
Before
6 months
1 year
Group
BAT
FK
TAU
Normals
Mean
50.0
49.2
57.2
61.3
SD
17.6
20.9
20.2
13.0
Mean
55.0
51.0
54.0
SD
18.5
21.4
15.8
Mean
55.8
51.7
57.3
SD
16.7
20.3
14.8
BAT
FK
TAU
Normals
21.8
24.4
22.7
15.0
13.8
15.1
18.9
11.6
14.7
17.1
23.9
14.8
13.2
18.8
16.5
21.0
15.8
14.5
16.7
14.2
comparison group ( p
01 ) and both BAT and
FK ( but not TAU ) had signiŽ cantly lower values
for the positive self-image than the comparison group ( p
01 ) . There were no signiŽ cant
differences on either the positive or the negative self-image before the intervention among
the treatment groups. In sum, all treatment
groups had a more negative self-image than the
comparison group before treatment.
The results showed that self-image improved over time in all three groups. More
exactly, positive self-image ( clusters 2, 3, and
4 —i.e., accept, love, and nourish self ) showed
a tendency to change over time ( p
06) and
a more detailed analysis revealed that cluster
2 ( accepting self ) improved signiŽ cantly ( p
01) while clusters 3 and 4 were more stable
over time. There were no signiŽ cant differences
COMPARATIVE STUDY OF NONSPECIFIC MSD PATIENTS
among the groups on positive self-image.
Negative self-image ( clusters 6, 7, 8 —i.e.,
blame, reject, and ignore self ) also improved
signiŽ cantly over time in all three groups
(p
01 ) . As with the psychological symptoms,
this signiŽ cant effect was between the Ž rst and
the following measurements but not between
the second and third measurement. There was
also a signiŽ cant interaction between time and
group ( p
05) due to the fact that TAU had
a higher value on the negative self-image than
BAT at the 6-month follow-up. These results are
illustrated in Figure 5.
The Ž gure shows that negative self-image
diminished ( i.e., improved ) in both BAT and
FK at 6 months but had increased again a little
at one year. In TAU, however, negative selfimage had increased at 6 months and then
diminished at the one year follow-up. One also
can see that positive self-image improved a little,
89
mostly in BAT, even if there were no signiŽ cant
differences among the groups. In sum there
was a certain positive development of self-image
over time in all three groups and it was especially
negative self-image that improved.
The ES values of positive and negative
self-image in the three groups and the criteria
for evaluating the magnitude of change are
shown in Figure 6.
The values for positive self-image are
considered as having no effect for TAU and
FK but a small effect for BAT. For negative
self-image, the values are considered to have a
small effect for FKand TAU and on the board to
small effects for FK. There were no signiŽ cant
differences among the groups with respect to
ES values.
Comparisons between men and women in
the total patient group were performed on
all initial status variables as well as outcome
Fig. 5 The development of positive and negative self-image over time in the treatment groups BAT, FK, and TAU
90
E.-B. MALMGREN-OLSSON ET AL.
Fig. 6 Effect-size (ES) values for positive and negative self-image in the treatment groups BAT, FK, and TAU
variables. No signiŽ cant differences were found
between gender except that the women
reported signiŽ cantly higher initial values on
pain severity ( p
05 ) . Parallel analyses were
made on the women separately since there were
so few men. The result did not differ from those
of the total patient group.
Outcome predicted from initial
status and amount of treatment
In order to study possible predictors for
outcome in the whole group of patients
age, gender, education, and initial symptoms
were correlated with outcome where outcome
was deŽ ned with ES values for psychological
symptoms, pain, and self-image. The results
showed no correlations between age, gender,
and outcome. Education level was correlated
to outcome, indicating that patients with more
education tend to improve more on life control
(r
311, p
01) and positive self-image
(r
254, p
05 ) but less on somatization
(r
248, p
05 ) .
When the relationship among the initial
status of psychological symptoms, pain, life
control, and self-image were examined the
analysis showed that a negative self-image
correlated with a high level of psychological
symptoms ( r
309, p
01) . A high level of
pain severity and pain interference showed
even higher correlations with psychological
symptoms ( r
407 – 497, p 001 ) . The scale
affective distress in MPI correlated strongly to
all scales of SCL-90 which means that they
both measure a state of psychological distress.
There were no correlations between pain and
self-image or between pain and life control.
However, perception of life control correlated
negatively with all kinds of psychological distress
( e.g, depression r
52 ) but also positively
with a positive self-image ( r
389 p
001 ) .
There also was a positive signiŽ cant
correlation between initial values of the
individual SCL-90 scales, MPI scales, and SASB
and their own ES values in the total patient
group. This means that patients with an initially
high level of psychological symptoms and pain
COMPARATIVE STUDY OF NONSPECIFIC MSD PATIENTS
improved more than those with a lower level
of symptoms and pain on most scales of
the SCL-90 ( r
518 – 748, p
01 ) and MPI
(r
304 – 685, p
01 ) . The same pattern
was found with SASB: An initially negative
self-image had a positive outcome on both
negative self-image ( r
527, p
01) and
positive self-image ( r
280, p
05 ) , while an
initially positive self-image showed a less positive
outcome ( r
496, p
05 )
As mentioned earlier, the amount of
treatment differed in the groups. Both BAT
and FK were ruled by a contract of 20 sessions
and the intervention should have been Ž nished
at the six-month follow-up, while in the TAU
group there was no time limit for the treatment
period or amount of treatment, which led to
a large difference in the range of treatment
sessions in that group. The only correlation
between amount of treatment and outcome in
the TAU group was a negative correlation with
ES values on positive self-image ( r
472,
05)
,
which
means
that
more
treatment
p
in the TAU group was associated with less
improvement of positive self-image.
DISCUSSION
The results of this study show that the clinical
groups had more psychological symptoms
and a more negative self-image initially than
the normal comparison groups. Although the
comparison groups are somewhat different
from the clinical groups with respect to gender
composition and age, in comparison to the
groups of this study such differences in normal
comparison groups have been found to be only
marginal for SCL-90 ( Andersen and Johansson,
1998 ) and for SASB ( Jeanneau and Armelius,
2000 ) . The fact that there was no difference
on PSI, but a difference in SSI on the SCL-90
shows that the patient groups in the present
study do not suffer from psychopathology but
from psychological distress. Thus, there is some
support for the idea that patients suffering from
nonspeciŽ c musculoskeletal disorders also have
problems of a psychological, but not psychiatric
nature. However, the results emphasize the
91
importance of paying attention to the multidimensional nature of the patient’s disorder,
not only when designing treatments but also
when evaluating treatment results.
The main purpose of this study was to
evaluate how psychological symptoms, pain,
and self-image in patients with nonspeciŽ c
musculoskeletal disorders changed after three
different models of treatment. The results
show that there were signiŽ cant positive
changes over time in all three treatment
models, especially with regard to diminishing
psychological symptoms and pain severity, but
also with respect to diminishing negative aspects
of the self-image. A critical question is whether
the improvements might be due to the time
factor and not to the interventions. The design
of the present study does not allow for a
conclusive answer to this question. However,
there seems to be a strong consensus in the
research area of chronic pain disorders that
treatment effects in general are very poor and,
therefore, we think that the interventions in the
present study might be due to speciŽ c treatment
effects. Naturally the patients’ problems might
 uctuate with time, but it has been shown that
patients with back pain who do not improve in
functional status within four weeks are likely to
become chronic ( Carey, Garrett, and Jackman,
2000 ) . For nonspeciŽ c neck-pain disorders the
severity of pain and a history of previous attacks
seem to be associated with a worse prognosis
( Bourghouts, Koes, and Bouter, 1998 ) .
Interestingly, the results indicate that all
three treatment models were equally effective
and that there were few signiŽ cant differences
between the models. However, the detailed
analysis of change by means of effect-size values
suggested that the Body Awareness Therapy
and Feldenkrais treatment models were a
little better than conventional physiotherapy
in reducing psychological symptoms and pain.
In order to evaluate the meaning of the
magnitudes of change achieved in the present
study a comparison with the general results of
change in psychotherapy research may be of
interest. According to the authoritative review
by Lambert, Shapiro, and Bergin ( 1994 ) of
the state of the art of psychotherapy outcome
92
E.-B. MALMGREN-OLSSON ET AL.
research, the average ES value of all published
outcome studies of psychotherapy is 0.82. This
effect is the sum of both general psychological effects due to attention and other factors
known as placebo effects and speciŽ c effects
of psychotherapeutic interventions. Their estimate is that the placebo effects have an average
ES value of 0.4, which may be thought of as an
upper limit for nonspeciŽ c treatment effects.
Our results show that especially BAT ( but
also FK) reached over this limit on many of
the variables on SCL-90, while TAU in general
reached 0.30 on most of the variables. In
other words one can say that on psychological
as well as somatic symptoms the two group
treatments BAT and FK have speciŽ c treatment
effects. The results thus suggest that the
combination of psychological and physiological
aspects in treatment seems to be slightly
superior to the conventional focus on just
the physiological aspects for musculoskeletal
disorders. The results suggest that working
with bodily symptoms and exercises in a
psychological context within a theoretically
cohesive framework of body and mind might
have more positive effects on psychological
symptoms of distress and pain than working
primarily with bodily symptoms.
However, there may be other explanations
for the difference in effect-size. As both
BAT and FK promote the patient’s active
participation in the treatment process they
are, perhaps, more successful in helping the
patients to discover and use their own resources
and therefore the effects of treatments might
be longer lasting. It seemed that a treatment
dose of 20 times over a period of three to
Ž ve months in BAT and FK was sufŽ cient to
see that the treatment effects were consistent
and had even improved six months after the
Ž nal intervention. In TAU where the treatment
sessions varied largely ( 5 –90 treatments ) , the
results showed, surprisingly, that there was
no correlation according to outcome between
patients receiving many or few treatments.
Maybe there is a risk that more passive
treatment methods reinforce the patient’s need
to have treatments.
The fact that the ES values for SASB
were much less than those for the SCL-90 is
consistent with the idea that self-image is a
more stable concept than the experience of
psychological symptoms or distress. The results
show that all three groups improved a little
in both the negative and positive aspects of
self-image, although the pattern of change
was different in the groups. Something that
is difŽ cult to explain and understand is that the
TAU group showed a more negative self-image
at the six month follow-up and then, at the one
year follow-up, improved most of all the groups.
One explanation to the deterioration at six
months might be that the pain level was almost
unchanged in TAU in comparison to the group
treatments. However the results indicate that
after the treatment period the patients accepted
themselves better and treated themselves less
negatively in terms of blaming and ignoring
themselves. At the end of treatment, however,
they had not quite improved to a normal selfimage. Perhaps this is not possible in such a
short time. To use self-image as an outcome
seems to be of interest, since generally a
negative self-image is related to different kinds
of psychological problems such eating disorders
( Wonderlich, Klein, and Counsil 1996) and to
personality disorders ( Öhman and Armelius,
1990 ) . It has been found that a negative
self-image is a prognostic sign for burnout
problems in staff, where self-image is more
important for feeling burned out than gender,
age, and type of work setting ( Jeanneau and
Armelius, 2000 ) In agreement with this study,
Mattsson ( 1998 ) and Monsen and colleagues
( 1994 ) also found that self-image improved
after treatment interventions for patients with
different chronic pain conditions. In summary,
empirical studies seem to show that there is a
relation among a negative self-image, different
psychological symptoms, and somatization. This
is an intriguing theory about cause and effect
that is beyond the scope of the present paper.
An interesting aspect in the study was
to look for predictors of outcome. One
strong predictor was that patients with a
more negative self-image and high initial
psychological symptoms and pain correlated
COMPARATIVE STUDY OF NONSPECIFIC MSD PATIENTS
signiŽ cantly to a better outcome than those
with a positive self-image and few symptoms.
This result is in agreement with other studies in
psychotherapy research ( Mohr et al, 1990 ) . One
interpretation is that a negative self-image is an
expression of suffering and a suffering person
might be motivated to change. In contrast, a
person with a positive self-image is satisŽ ed
with him or herself and does not feel the
need to change, but expects change in his
or her physical condition to take place by
other means such as medication, massage, or
surgery. This seems to be a characteristic of
patients with a high somatization tendency. On
the other hand, a positive self-image together
with a strong feeling of life control seems to
characterize a more healthy person. These two
constructs were negatively correlated with all
kinds of psychological distress.
Patients with a higher education showed
more improvement on self-image and perceived
life control but less improvement on somatization. This might illustrate that their needs
for help were more of a psychological than
a physical nature. Probably their work situation is less physically demanding than for those
with a lower education. That a higher level of
education in general is important for a good
rehabilitation outcome has been conŽ rmed in
other studies ( Straaton et al, 1995) . Interestingly, there was no relationship between gender
and outcome. This might be due to the small
number of men in this study. In general there
are few treatment studies that have focused
on gender-speciŽ c patterns of outcome ( SBU,
2000a, 2000b ) . In one study the effects of
a multidisciplinary program for chronic back
pain disorders were examined the men seemed
to improve more on physical strength measurements than the women did ( Alaranto et al,
1994 ) . Perhaps treatment interventions that
focus more on physical function attract more
men, while women are more interested in interventions also containing psychological aspects.
From clinical experience we know that there are
many more women than men participating in
group treatment interventions with some kind
of body awareness techniques.
93
There are some methodological problems
in the study. The fact that there were very
few signiŽ cant differences among the three
groups with regard to treatment effects over
time can have several causes. First, it may be
seen as a statistical power problem due to too
small sample size and a large variability in data.
In therapy research the lack of power is not
a minor methodological annoyance ( Bergin
and GarŽ eld, 1994 ) . In studies comparing
treatment versus no-treatment, statistics are
generally sufŽ ciently powerful to detect group
differences because of relatively large effect
sizes. In contrast, comparisons of two or more
active treatments are likely to produce smaller
effect sizes and therefore the statistical power
is often relatively low. According to Kazdin
and Bass ( 1989 ) when comparing different
treatment models the groups should contain
at least 70 persons each. Second, it might
be due to the fact that the magnitude of
effect is relatively small for physiologically-based
treatments for this group of patients. According
to the reviews of the Ž eld we should not expect
large treatment effects. Third, the observed
effects might be nonspeciŽ c and might belong
to what is considered to be general placebo
effects of treatment. Fourth, it might be true
that there are no systematic differences between
effective treatments, which means that all are
approximately equally effective. This seems to
be the state of the art of psychotherapy research,
where controlled efŽ cacy studies comparing
different treatments have come to a point
where the allegiance of the investigators seems
to explain most of the outcome differences
( Luborsky et al, 1999) .
The major weakness of the present study is
that the patients were not randomly assigned
to the treatment groups. Thus, there was no
control over the selection of patients, which
might explain outcome differences. In the
present study however, there are circumstances
that reduce the impact of this threat to the
internal validity of the conclusions ( Cook
and Campbell, 1979) . First, the differences in
outcome are very small, which means that there
is very little reason to suspect that a selection
bias has in uenced the results. Second, there
94
E.-B. MALMGREN-OLSSON ET AL.
are no signiŽ cant differences at all according
to background variables before intervention in
the three groups. One explanation for the
fact that the groups were relatively alike may
be that the information sent to all referring
physicians about the selection criteria was
carefully deŽ ned both orally and in written
form and also that the patients were examined
by both physicians and physiotherapists with a
view to making sure that they fulŽ lled these
criteria.
In conclusion, this study shows that psychological symptoms, pain, and a negative selfimage changed signiŽ cantly for the better in
all treatment groups and that there were few
signiŽ cant differences between the groups even
if effect-size measurements showed a tendency
for the group treatments, and especially BAT,
to be a little better on both psychological
symptoms and pain than conventional treatment. The results also showed that the patient
groups differed signiŽ cantly from the comparison groups, which indicates that psychological
factors are important to include in the evaluation and treatment planning for patients with
nonspeciŽ c musculoskeletal pain disorders.
Acknowledgments
The present study was supported by grants
from the County Council of Västerbotten.
Many thanks to associate professor Inga-Britt
Bränholm at the department of Community
Medicine and Rehabilitation, Umea University
for valuable advice in the study and to my
colleague Kina Meurle-Hallberg for reading the
manuscript.
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