[Efficacy of inpatient rehabilitation for chronic back pain in Germany: update of a systematic review].
BACKGROUND
The ninth book of the German social code, SGB IX, has intensified questions on the effectiveness and usefulness of medical rehabilitation, a multimodal multidisciplinary team care model, especially but not exclusively for chronic back pain. In 2002 back pain was the reported leading cause for 29 % of all medical and other rehabilitative services provided by German statutory pension funds. A previous systematic review of all available German studies (January 1980 to June 2001) analysed the effectiveness of inpatient rehabilitation for chronic back pain. The present report provides an update and critical appraisal of the review.


METHODS
Again we conducted a systematic search for relevant German studies from between July 2001 and December 2003 using electronic data bases, hand-searching of congress abstracts and postal questionnaires. The quality of relevant studies was assessed according to the recommendations of the Cochrane Back Review Group. For each study effect sizes for up to six central outcome parameters were calculated using pre-post comparisons from short and medium term follow-ups, they were correlated with prognostically relevant characteristics of the studies and samples. The combined weighted intra-group effect sizes were compared with results from international studies.


RESULTS
16 studies, both controlled and uncontrolled, were included. Again we could not identify any study confirming the effectiveness of medical rehabilitation in chronic back pain compared to no treatment or usual care. The methodological quality of the new studies did not seem to exceed that of the earlier ones. Depending on the outcome variable, small effects (e. g. on functional ability) to relevant effects (e. g. vitality) can be observed at or immediately after the end of rehabilitation. Now the effects after three to 12 months seem to be smaller than previously observed.


CONCLUSIONS
The small size of medium term effects indicates a basic problem of inpatient rehabilitation for chronic back pain in Germany. This becomes even greater when the results of international controlled studies are used as reference. Possible reasons for the disappointing situation (weak methodology, inappropriate selection of patients, weak intervention) are to be discussed. At present, we have no convincing evidence for a general effectiveness of Germany's system of inpatient rehabilitation for chronic back pain.
Hüppe
A
A
Institut für Sozialmedizin, Universitätsklinikum S-H Campus Lübeck. angelika.hueppe@sozmed.uni-luebeck.de
Raspe
H
H
D018849:Controlled Clinical Trials as Topic / Q000706:statistics & numerical data; D003430:Cross-Sectional Studies; D004185:Disability Evaluation; D005858:Germany; D006801:Humans; D008137:Longitudinal Studies; D017116:Low Back Pain / Q000453:epidemiology / Q000534:rehabilitation*; D010043:Outcome and Process Assessment, Health Care / Q000706:statistics & numerical data; D010343:Patient Admission; D018579:Patient Selection; D011379:Prognosis; D016032:Randomized Controlled Trials as Topic / Q000706:statistics & numerical data; D012050:Rehabilitation, Vocational / Q000706:statistics & numerical data; D013223:Statistics as Topic; D016896:Treatment Outcome