Multidisciplinary rehabilitation versus usual care for chronic low back pain in the community: effects on quality of life

Abstract

BACKGROUND CONTEXT: 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.

PURPOSE: 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.

STUDY DESIGN: 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.

PATIENT SAMPLE: 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.

OUTCOME MEASURES: 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.

Introduction

Back pain is one of the most common medical and socioeconomic problems in the industrialized countries [1]. Most back pain problems are nonspecific in that no underlying pathophysiological or anatomical defects explain the pain on a scientific level of evidence [2], [3]. The biopsychosocial model of chronic back pain attributes biomechanical dysfunction, physical deconditioning and psychosocial stressors as interrelating causes of chronic, entrenched disability [4].

Most patients with chronic nonspecific back pain are treated by nonmultidisciplinary therapies of health-care providers in the community. However, in controlled studies, few of the nonmultidisciplinary therapies have been proven to be effective for the treatment of chronic lower back pain [5]. It has been reported from a national survey in the United States that there is little consensus among physicians regarding effective diagnostic tests and therapeutic interventions in the treatment of acute and chronic low back pain [6], [7]. Additionally, these diagnostic tests and therapeutic interventions did not agree with the recommendations of the Quebec Task Force on Spinal Disorders [1]. Thus, most patients with chronic back pain in the community are currently managed by many different interventions with uncertain scientific evidence regarding their effectiveness.

In contrast, intensive multidisciplinary biopsychosocial rehabilitation with functional restoration has been shown in controlled studies to improve pain and function in patients with chronic low back pain [8], [9]. Originally, functional restoration was characterized by an interdisciplinary, medically directed team approach that is provided by a highly qualified treatment staff with frequent team conferences [4]. However, the more complex structure and higher costs of functional restoration programs as compared with usual care limited the implementation of back pain rehabilitation centers as an option for routine treatment.

To overcome the structural deficits in back pain management in the community, we tested the outcome of a multidisciplinary rehabilitation program (MRP) that was organized by cooperation of interested and qualified local health-care providers in the community. The costs for the MRP could be kept low and paid by the patients because of treatments in group settings and sharing of health-care structures that are cofinanced from therapies other than MRP. However, less specialization of the treatment staff on therapy of back pain and less interdisciplinary cooperation may cause lower outcome of MRP when compared with the functional restoration program as described by Gatchel et al. [4]. Nevertheless, if this “prototype” of an MRP would prove to be more effective than the nonmultidisciplinary treatments of usual care, the program might be copied in different towns and integrated in the community medicine. As a consequence, treatment capacity and local availability for MRP are expected to increase. Furthermore, MRP could be applied earlier in the progress of back pain chronification and might be more effective.

The aim of the present study was to compare the outcome of MRP versus usual care for treatment of back pain in community settings. Outcome was assessed from self-reported questionnaires as differences from baseline to follow-up after 6 months. As the main outcome measure, we evaluated the health-related quality of life by means of the German version of the Short Form 36 (SF-36) [10]. The SF-36 quantifies different aspects of the health-related physical and emotional well-being in eight domains and has been proven effective as a means of tracking group outcomes after interventions to treat chronic back pain [11], [12], [13]. Furthermore, the primary aim of functional restoration—better coping with biomechanical, psychosocial and socioeconomic factors involved in disability behaviors—addresses particularly the role limitations of patients with back pain. The effects of MRP and conventional care on the specific SF-36 domains are compared with those on pain intensity, pain-related interference with function, depression and days off work.