Multidisciplinary rehabilitation versus usual care for chronic low back pain in the community: effects on quality of life.
BACKGROUND
Multidisciplinary biopsychosocial rehabilitation has been shown in controlled studies to improve pain and function in patients with chronic back pain. However, specialized back pain rehabilitation centers are rare and only a few patients can participate on this therapy. Implementation of multidisciplinary rehabilitation services in community medicine may enhance both early availability and treatment capacity for comprehensive back pain rehabilitation.


OBJECTIVE
To compare the outcome of a multidisciplinary rehabilitation program (MRP) that was organized by cooperation of local health-care providers in the community with that of the usual care by independent physicians for patients with chronic low back pain.


METHODS
A comparison between the outcomes (follow-up time of 6 months) of treatment for chronic back pain in the community in a prospective intervention group versus a prospective observational usual care group.


METHODS
All patients were recruited from independent physicians in the community of a selected region who participated voluntarily in the study. Patients were included in the study if they were seeking treatment of pain in the back with possible irradiation into the legs, the pain persisted for at least 3 months without decreasing intensity and there was no indication for surgical intervention.


METHODS
Outcome was assessed from patients' responses in self-report questionnaires at baseline and after an interval of 6 months. For outcome, we evaluated the health-related quality of life (German version of Short Form [SF] 36), the average pain severity (Numeric Rating Scale), the pain-related interference of function (German version of Brief Pain Inventory), depression (Allgemeine Depressionsskele), time off from work within 3 months before entering and leaving the study and the self-appraisal of improvement.


METHODS
In a baseline group, the independent physicians treated the patients with usual care. In the intervention group, the patients were referred by the independent physicians to the study coordinator in the outpatient facilities of the Departments of Neurology or Orthopedics for inclusion in the MRP. The MRP was organized by cooperation of local health-care providers in the community with different specialties (sport teachers, clinical psychologist, physiotherapist and physician) who were experienced in the management of back pain. The MRP (4 hours per day, 3 days per week, 20 days) included 1.5 hours restorative exercise therapy, 0.5 hours physiotherapy, 1 hour cognitive-behavioral therapy, 0.5 hours progressive muscle relaxation and 0.5 hours education.


RESULTS
Complete data sets were obtained from 157 patients in the usual care group (documented by 35 independent physicians) and 51 patients in the MRP group. Patients of the MRP group improved in the physical and mental health domains of the SF-36 more than patients treated by usual care (p<.05). Furthermore, days off work were more (p<.05) reduced by the MRP (16+/-35 days) than by usual care (-2+/-39 days). Finally, overall appraisal of successful outcome was better (p<.01) after MRP (54% of patients) as compared with usual care (24% of patients). However, the pain intensity (NRS), the pain-related interference with function (Brief Pain Inventory; BPI) and the depression scores (ADS) did not differ significantly between both groups.


CONCLUSIONS
MRP is promising to improve health-related quality of life for patients with chronic back pain in the community. Before implementation of MRP in the repertoire of community medicine, superiority of MRP over usual care should be confirmed by a randomized controlled trial.
Department of Neurology, University of Erlangen-Nuremberg, D-91054 Erlangen, Germany. eberhard.lang@rzmail.uni-erlangen.de
Eberhard
E
Lang
Klaus
K
Liebig
Sabine
S
Kastner
Bernhard
B
Neundörfer
P
P
Heuschmann
D002908:Chronic Disease; D003131:Combined Modality Therapy; D003154:Community Medicine; D005260:Female; D006304:Health Status; D006801:Humans; D017116:Low Back Pain / Q000503:physiopathology / Q000534:rehabilitation*; D008297:Male; D008875:Middle Aged; D011320:Primary Health Care; D011788:Quality of Life; D011795:Surveys and Questionnaires; D016896:Treatment Outcome