@phdthesis{01KPDAB9YRCJAEZ2ZVRSCX7DB5,
  abstract     = {{Low back pain (LBP) is one of the most common and disabling musculoskeletal conditions worldwide. LBP is typically regarded as a multifactorial condition, resulting from a complex interplay of biological, psychological, and social factors that can both predispose individuals to LBP and contribute to its persistence. Psychological factors are thought to influence movement performance in LBP. However, current theoretical models often describe motor control changes only in general terms (e.g., deconditioning, overuse), without specifying the underlying motor mechanisms. Additionally, as LBP becomes persistent, the clinical presentation tends to increase in complexity. A common feature is the co-occurrence of mental disorders alongside persistent LBP. However, individuals with psychiatric comorbidities are often excluded from studies evaluating interdisciplinary pain treatments. Therefore, this dissertation aimed to enhance our understanding of how psychological factors influence movement performance in individuals with non-specific LBP, and to evaluate the effectiveness of an interdisciplinary multimodal healthcare program for individuals with persistent spinal pain and comorbid mental disorders. To achieve these aims, four studies were conducted and one randomized clinical trial protocol was developed. The dissertation is structured into two main parts, each addressing a distinct research objective.

Part I comprises two chapters, including a systematic review and a cross-sectional study, and addresses the following research question: How do psychological factors (i.e., attention, fear of movement, and pain catastrophizing) influence movement-related outcomes in non-specific LBP? 

Chapter 1 presents a systematic review on the influence of attention — both as a dispositional trait and as a modifiable context-dependent state — on movement-related outcomes in individuals with non-specific LBP. Twenty-eight studies were included and categorized into three clusters: implicit attention manipulation, explicit attention manipulation, and self-reported measures of attention. Findings were grouped by motor outcome (i.e., muscle activity, muscle timing, gait parameters, balance parameters, trunk flexibility, muscle strength, functional performance, and kinematics) and by LBP group (i.e., acute, recurrent, chronic). Although the available evidence was highly heterogeneous and most conclusions regarding a specific motor outcome were supported by only limited evidence, findings suggest that various forms of externally directed attention may normalize movement-related parameters in individuals with chronic LBP to levels comparable to those observed in pain-free controls. Chapter 2 reports on a cross-sectional study in which anticipatory postural adjustment (APA) onset times across 10 trunk muscles were assessed during a rapid arm movement task in three groups: pain-free individuals, patients with recurrent LBP in remission, and patients with chronic LBP. While no significant between-group differences were observed at the level of individual muscles, cluster analysis identified three participant subgroups, independent of LBP status, characterized by a pattern of early, similar, or delayed APA onsets across trunk muscles relative to deltoid activation. Psychological factors increased progressively across these clusters, with highest levels of fear of movement, pain vigilance/awareness, and pain catastrophizing observed in the cluster with delayed APA onset times. 

Part II comprises three chapters, including a randomized clinical trial protocol and two descriptive studies, and addresses the following research questions: What are the intermediate and long-term effects of two types of exercise therapy on brain and paravertebral muscle structure and function in recurrent LBP? And what is the effectiveness of an interdisciplinary multimodal healthcare program for individuals with chronic spinal pain and comorbid mental disorders?

Chapter 3 outlines the protocol of a randomized clinical trial comparing specific skilled motor training with general exercise training in individuals with recurrent non-specific LBP. The results of this study will contribute to our understanding of the effects of exercise therapy on motor control parameters, as well as the potential moderating role of psychological factors in treatment response. Chapters 4 and 5 evaluated the effectiveness of a 20-week interdisciplinary multimodal integrative healthcare program for individuals with chronic spinal pain and comorbid mental disorders implemented in a mental healthcare setting. Both studies demonstrated significant improvements in health-related quality of life, symptoms of psychopathology, and pain-related disability, with treatment gains sustained over a 12-month follow-up period. Importantly, both studies included patients who are typically excluded from pain research due to psychiatric comorbidities, thereby addressing a critical gap in the evidence base.

In conclusion, this dissertation advances our understanding of how psychological factors influence movement-related outcomes in non-specific LBP. It also provides promising evidence for the feasibility and effectiveness of a transdiagnostic interdisciplinary intervention targeting both physical and psychological symptoms in individuals with persistent spinal pain. Future research should explore which factors predict treatment response and examine how these insights might guide the personalization of intervention strategies within these interdisciplinary multimodal interventions. In addition, studies should aim to disentangle the specific contribution of individual treatment components within interdisciplinary multimodal programs. Further research is also needed to elucidate the central mechanisms through which psychological factors influence motor control in non-specific LBP. Finally, acute and recurrent LBP populations remain underrepresented in current research and should receive greater attention in future studies.}},
  author       = {{Wijnen, Jaap}},
  language     = {{eng}},
  pages        = {{361}},
  publisher    = {{Ghent University. Faculty of Medicine and Health Sciences}},
  school       = {{Ghent University}},
  title        = {{Mind and motion in low back pain : psychological factors, motor control and integrative treatments}},
  year         = {{2026}},
}