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Efficacy of Multidisciplinary Treatment forPatients With Chronic Low Back Pain A

Prospective Clinical Study in 395 Patients

Article in Journal of clinical rheumatology: practical reports on rheumatic & musculoskeletal diseases ·March 2012

Impact Factor: 1.08 · DOI: 10.1097/RHU.0b013e318247b96a · Source: PubMed

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10 authors, including:

Sébastien Hagmann

Universität Heidelberg

31 PUBLICATIONS 288 CITATIONS

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Anita Zahlten

Novartis Oncology


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Marcus Schiltenwolf


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Eva Neubauer



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Efficacy of Multidisciplinary Treatment for Patients With Chronic Low Back Pain

A Prospective Clinical Study in 395 Patients

Babak Moradi, MD, Sebastién Hagmann, MD, Anita Zahlten-Hinguranage, PhD, Fernanda Caldeira, MSc, Cornelia Putz, MD, Nils Rosshirt, Eva Schönit, Alireza Mesrian, MD,

Marcus Schiltenwolf, MD, PhD, and Eva Neubauer, PhD

Background: The effectiveness of multidisciplinary treatment pro-grams varies throughout the literature, and it remains controversial how

therapy outcome is affected by patients’ individual parameters and which

treatment settings work best.

Objectives: We setout to examinethe impact of patient variables on theeffectiveness of a 3-week multidisciplinary treatment program in patients

with chronic low back pain. By presenting effect sizes, we aimed to enable

the comparison of our findings with other studies across disciplines.

Methods: Data on 395 patients were prospectively collected at studyentry, at the end of the program (T 1) and after 6 months’ follow-up (T 2).

Relevant therapy outcomes were analyzed by presenting effect sizes with

Cohen’s d . Group comparisons were performed for sociodemographic

and clinical features to determine the impact on therapy outcome.

Results: Medium effect sizes (d = j0.6 to j0.7) were shown for visualanalog scale (VAS) after treatment and at T 2, indicating clinically relevant

pain relief. Significant changes in pain-related disability were observed

immediately at T 1 with a strong treatment effect (d = 0.8). Functional

capacity was improved with low to medium effect sizes (0.4 Y 0.5). Quality-

of-life subscales (36-item Short Form Health Survey) improved signifi-

cantly at T 1 for physical function, vitality, and mental health (d = 0.5 Y

0.8).Center for Epidemiological Studies Y Depression Scale scores improved

significantly with strong effect sizes of d = 0.7. Sociodemographic para-

meters displayed a significant impact on effect sizes for visual analog

scale at T 2, with females (d = j0.9), age group 30 to 39 years (d = j1),

and patients with low physical job exposure (d = j0.9) benefiting most.

An increase in number of pain locations (j0.7) and severity of accom-

panying pain (j0.7) in other body areas significantly impaired therapy

outcome and effect sizes of VAS.

Conclusions: Thus, multidisciplinary treatment ameliorates pain,functional restoration, andqualityof life with mediumto high effect sizes

even for patients with a long history of chronic back pain. Effect sizes are

higher than for monodisciplinary treatments and treatment effects

remained stable at 6-month follow-up in a longitudinal uncontrolled

study design. Thus, we believe that multidisciplinary treatment is vital

for the treatment of patients with chronic low back pain. The impact of

sociodemographic and pain-related parameters needs to be taken into

accountwhen including patients in an appropriate treatment program. We

emphasize the presentation of effect sizes as a vital treatment evaluation

to enable cross-sectional comparison of therapy outcomes.

Key Words: chronic low back pain, multidisciplinary treatment, efficacy

of treatment, Cohen’s d , effect size, effectiveness

( J Clin Rheumatol 2012;18: 76 Y 82)

Chronic low back pain (CLBP), with its associated disabilitiesand costs, is the most common cause of long-term disabilityin the working population and represents a serious problem for our health care systems.1 The fact that 70% to 85% of the pop-ulation in western societies experience musculoskeletal pain at least once in their lifetime, with point prevalence of approxi-mately 30%, underlines the ‘‘epidemic proportions’’ of this health problem.1 Y 3 The socioeconomic impact is known to be enormousand accounts for one third of all health care resources and costs.2,4

Only a small proportion of the costs are incurred by therapy; themajor costs result from loss of productivity, work absenteeism,and disablement.2,4 Even after an intensive diagnostic workup,the exact cause of musculoskeletal pain remains unestablished in approximately 85% of cases; however, specific causes (e.g.,tumors, infection, fractures, and herniated lumbar disks) have to be excluded before treatment.3,5 Some 7% to 10% of all cases of initial LBP become chronic, and these patients account for 80%of the costs of LBP.5

Thus, CLBP is multifactorial with respect to its causes, and the treatment is correspondingly diverse.6 A number of different treatment options for patients with CLBP exist, but the reported success rates vary dramatically.6 Y 9 Multidisciplinary therapyincorporating multiple treatment components such as intensive physical exercises and biopsychosocial and behavioral inter-ventions is accepted to yield higher success rates than purely biomedical treatment and is considered the criterion standard by national and international pain societies in Europe and elsewhere.8,10 Y 15

However, it is still unclear which treatment settings work

best and how therapy outcome is affected by patients’ individual parameters.14,15 To tailor treatment settings and patient selectionfor better therapy outcome, it is pivotal to compare different set-tings. The comparison of different rehabilitation programs within1 institution remains difficult owing to ethical considerationsand the enormous costs of intensive multidisciplinary treatment.Thus, it is of special interest to compare therapy outcome acrossdisciplines. Profound comparison remains difficult, however,owing to inconsistent study settings, outcome parameters, and statistical methods.

Estimates of effect size permit researchers to comparefindings among studies and across disciplines. This form of sta-tistical evaluation allows closer comparison of therapy outcome between multidisciplinary treatment and other treatment options,

for example, inpatient or outpatient nonmultidisciplinary treat-ments for patients with CLBP.

ORIGINAL ARTICLE

76 www.jclinrheum.com JCR: Journal of Clinical Rheumatology & Volume 18, Number 2, March 2012

From the Orthopaedic Clinic, University of Heidelberg, Germany.The authors declare no conflict of interest.Correspondence: Babak Moradi, MD, University Clinic of Heidelberg,

Department of Orthopaedics, Trauma Surgery and Paraplegiology,Schlierbacher Landstrasse 200 a, 69118 Heidelberg, Germany.E-mail: [email protected].

Copyright * 2012 by Lippincott Williams & Wilkins

ISSN: 1076-1608/12/1802 Y

0076DOI: 10.1097/RHU.0b013e318247b96a

Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.


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The purpose of this prospective study was to evaluate theeffectiveness of multidisciplinary treatment program in patientswith CLBP by determining effect sizes of different outcome parameters. Further, we aimed to analyze the impact of socio-demographic and clinical parameters on therapy outcome.

METHODS

Study DesignA convenience sample of 395 patients was recruited from

our institution in a prospective cohort study with 6 months’follow-up. All patients underwent 3 weeks’ inpatient multidis-ciplinary therapy as described below. Assessment and treatment of the patients were not altered for this study. Informed consent was obtained from all patients. The ethics committee of theUniversity of Heidelberg approved the study. The treating phy-sicians had referred all patients to the clinic without preselection by an insurance company or the clinic.

Inclusion CriteriaConsenting patients of working age (18 Y 65 years) who had

an adequate command of the German language and were ex- periencing CLBP were enrolled into the study. Chronic low back pain was defined as disabling pain of at least 3 months’ durationthat led to the patients’ being on sick leave for at least 6 weeks.The patients generally had a long history of pain and had alreadyundergone several conventional forms of biomedical treatment.In most cases, the patients were being referred to the multidis-ciplinary therapy program for the first time owing to failure of standard therapy.

Exclusion CriteriaExcluded from the study were patients with specific etiology

of pain such as tumor disease; trauma/fracture; inflammatory

systemic disease or infection, for example, spondylodiscitis; se-vere degenerative changes; and rheumatological disease. Patientswith acute clinical symptoms due to structural pathology of thelumbar spine such as nucleus pulposus prolapse with corre-sponding radicular pain, spinal stenosis, or spondylolisthesis withclaudicatio spinalis were also excluded. Further excluded were patients with serious cardiopulmonary, vascular, or other internalmedical conditions; any sensorimotor and/or neurological defi-cits in the lower extremity; and surgery in the 12 months beforecommencement of multidisciplinary therapy. Patients with pend-ing litigation regarding pension demands and workers’ compen-sations were excluded.

Multidisciplinary Treatment

Patients underwent 3 weeks’ multidisciplinary therapy asinpatients, with 8-hour sessions on 5 d/wk for a total of 120 hoursof treatment. This multidisciplinary approach embraces biologi-cal, social, and psychological aspects in one common explanationof the patient’s pain. Its goal is to restore the patients’ physical and psychosocial abilities, to increase their knowledge of back ergo-nomics and their adoption of protective behavior, to improve their positive skills with regard to individual coping and emotionalcontrol, and to increase their day-to-day activity levels and func-tioning at home so as to facilitate a return to the workplace. It integrates physical exercises, ergonomic training, psychotherapy, patient education, behavioral therapy, and workplace-based in-terventions on an individual basis and in group sessions (12 patients per group). Patients’ physical ability was assessed at study

entry by the treating physiotherapist through a comprehensive physical examination measuring physical performance, force,

endurance, and flexibility. Therapy goals were determined to-gether with the patient, and a program for functional restorationwith an operant behavioral approach was performed. Exerciseincluded walking, medical training therapy, and free sports indoor and outdoor. Continuous education by the medical staff gaveinformation on the goal of alleviating fear for movement and explained increasing pain due to increasing workout as a physicaladaptation. Cognitive-behavioral therapy was conducted by aninterdisciplinary team of physician (orthopedic surgeon), psy-chologist, and physiotherapist to enhance patients’ understandingof the nature and function of their pain, its social and psychologi-cal aspects, and its link to work and lifestyle. The primary goalswere to increase patients’ physical and mental coping strategies and to encourage patients’ independence of medical treatment offers.The psychotherapy embraced analysis of individual psychosocialfactors and conflicts contributing to persistent LBP. Stress behavior was analyzed for situations in which pain and stress were experi-enced. Psychotherapeutic group sessions also included psycho-education with behavioral therapy, problem solving, and stressrelaxation. Additional individual therapy consisted of daily ses-

sions with physicians and psychologists, individual physiotherapy,and cognitive-behavioral therapy.

After completion of their treatment programs, the patientswere discharged without further interventions by the hospitalteam. They were allowed to contact the physician who had re-ferred them for therapy, but they were encouraged to managesimilar further pain episodes on their own without immediatelycontacting a physician. Further utilization of medical servicesafter completion of the therapy program was not monitored.

Evaluation of Baseline DataVarious independent variables were assessed on the basis

of a questionnaire in German completed by the patients beforethey started the multidisciplinary therapy. These baseline data

included sociodemographic variables, occupational, and workplace characteristics. Data on self-reported pain (visual analogscale[VAS]), functional capacity (Funktionsfragebogen Hannover-Ruecken [FFbH-R]), pain disability (Pain Disability Index German[PDI-G]), quality of life (36-item Short Form Health Survey [SF-36]) and Center for Epidemiological Studies Y Depression Scale(CES-D) were prospectively collected at baseline (day 1), at theend of treatment on day 21 (T 1), and at the 6-month treatment follow-up (T 2). All measures are valid, reliable, and widely used instruments in medical outcome studies.

Visual Analog Scale

Patients rated their current pain intensity on a VAS from0 to 10.

Pain Disability Index

Measures of pain-related disability in which greater levelsof disability are reflected by higher scores on a 10-point scalewere assessed with PDI-G.16,17 This validated questionnaire con-sists of 7 items representing the impact of pain on essential lifeactivities. The overall score is expressed by an aggregate value of functional capacity. The resulting PDI-G scores can range between0 (minimal disability) and 70 (maximal disability).

Functional Back Capacity

Measures of functional back capacity were assessed withFFbH-R.18 This validated questionnaire consists of 12 itemsrepresenting physical activities of daily living (e.g., sitting on a

chair for 9

1 hour). The overall score is expressed by an aggregatevalue of functional capacity. The resulting FFbH-R scores can

JCR: Journal of Clinical Rheumatology & Volume 18, Number 2, March 2012 Efficacy of Multidisciplinary Treatment

* 2012 Lippincott Williams & Wilkins www.jclinrheum.com 77



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range between 0 (minimal functional capacity) and 100 (maximalfunctional capacity).

36-Item Short Form Health Survey

Generic health status was assessed by using the subscales

‘‘physical functioning,’’ ‘‘mental health,’’ and ‘‘vitality’’ of theGerman version of SF-36, a widely used instrument evaluatingquality of life.19

Center for Epidemiological Studies Y Depression Scale

Psychological evaluation, based on a screening for the prevalence of depressive disorders, was performed using theGerman equivalent of the Center for Epidemiological Studies Y Depression Scale (CES-D).20 This inventory consists of 20items evaluating the level of depressive symptoms. A score of 16 or higher on the questionnaire indicated a depressive episode.

Classification of Stage of Chronicity

According to the classification of von Korff et al.,21

awidely used and validated instrument, patients were assigned togroups with different stages of chronicity. Classification was based on the evaluation of the following items: pain intensity(0 Y 10; pain right now, average pain, worst pain), days of pain inthe previous 6 months, time since onset, disability due to pain(three 0 Y 10 interference ratings), and disability days. The itemswere summarized to a characteristic pain intensity score and todisability points (disability score and disability days) and led toa final classification into 5 grades of chronic pain:

Grade 0: pain free (no pain problem).Grade 1: low disability, low intensity (characteristic pain

intensity G50; G3 disability points).Grade 2: low disability, high intensity (characteristic pain

intensity Q50; G3 disability points).Grade 3: high disability, moderately limiting (3 Y 4 disability

points, regardless of characteristic pain intensity).Grade 4: high disability, severely limiting (5 Y 64 disability

points, regardless of characteristic pain intensity).

Evaluation of Outcome Variables andStatistical Analysis

Patients’ health status was assessed at the 3 assessment time points: before treatment (T 0), after treatment (T 1), and at the6-month follow-up (T 2). The therapy outcome after treatment and at 6 months was measured according to the above-mentioned outcome criteria. Descriptive statistics for each of the mea-sures evaluated were computed. The pre j post comparisonswere conducted with Fisher’s test.

Cohen’s d effect sizes were calculated for VAS, CES-D,PDI-G, FFbH-R, and SF-36 by subtracting the posttreatment mean from the pretreatment mean and dividing the result bythe pretreatment SD. This strategy allows the generation of standardized values for change based on dependent variables,even in the absence of a control group.22 All data were ana-lyzed using the SPSS statistical application for Windows(version 17.0; SPSS, Inc., Chicago, IL).

effect size d ¼ ½ posttreatment mean ½ pretreatment mean

pretreatment SD

The generally accepted regression benchmark for effect size comes from Cohen23: 0.20 is a minimal effect (but signif-

icant in social science research), 0.50 is a medium effect, any-thing equal to or greater than 0.80 is a large effect size. 23,24

RESULTS

Study Population and Evaluation of Baseline DataThree hundred ninety-five patients (227 women and 168

men) who met the inclusion and exclusion criteria underwent

TABLE 1. Sociodemographic and Clinical Features of theStudy Population (n = 395) at Study Entry (T 0)

Sociodemographic data

n 395

Age, mean (SD) [range], y 44.25 (9.1) [22 Y 64]

Male, % 42.5

Female, % 57.5

Body mass index, mean (SD)[range], kg/m2

25.1 (4.5) [16.1 Y 47.6]

Marital status, n (%)

Single 85 (21.5)

Married 251 (63.5)

Divorced 41 (10.4)Widowed 4 (1.0)

Smoker, n (%) 138 (34.9)

Regular daily sports activity, n (%) 265 (67.1)

Occupational status

Educational level, n (%)

Low 152 (38.5)

Intermediate 120 (30.2)

High 113 (28.7)

No data 10 (2.6)

Professional education, n (%) 335 (84.9)

Physical job exposure, n (%)

Low 123 (31.1)

Moderate 146 (37.1)High 113 (28.5)

Job satisfaction, n (%)

High 188 (47.4)

Low 86 (21.7)

No data 47 (18.7)

Days of sick leave, n (%)

1 Y 10 d 48 (12.2)

11 Y 30 d 61 (15.4)

31 Y 65 d 41 (10.4)

965 d 44 (11.1)

No data 45 (11.4)

Present job security, n (%) 68 (17.2)

Evaluation of pain

Subjective pain perception (VAS),mean (SD)

51.8 (20.41)

Duration of current pain, mean (SD), mo 16.4 (25.9)

Stage of chronicity, n (%)

Stage 2 125 (31.6)

Stage 3 167 (42.3)

Stage 4 89 (26.1)

Functional status

SF-36 physical functioning, mean (SD) 60.92 (19.9)

SF-36 mental health, mean (SD) 51.26 (16.30)

SF-36 vitality, mean (SD) 44.77 (19.02)

Functional disability (FFbH-R), mean (SD) 64.5 (19.1)

Existing depression (CES-D 916), n (%) 136 (34.4)

Pain disability (PDI-G), mean (SD) 26.66 (12.3)

Moradi et al JCR: Journal of Clinical Rheumatology & Volume 18, Number 2, March 2012

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multidisciplinary treatment for CLBP at the Orthopedic Clinic,University of Heidelberg. The patients’ mean age at study entrywas 44.25 (9.1) years, and their mean body mass index was 25.1(4.5) kg/m2. All patients experienced CLBP as their mainsymptom, with a mean pain duration of 16.4 (25.9) months.Most patients (42.3%) displayed stage 3 of chronicity accordingto von Korff et al.21 The mean duration of sick leave was 50.1(95.4) days. A detailed description of baseline characteristics of the study population is shown in Table 1.

Comparison of Outcome Variables at the End of Treatment and at the 6-Month Follow-Up

Patients showed a significant improvement in all outcomemeasures, including subjective pain perception (VAS), functional back capacity (FFbH-R), and general health status (SF-36), after multidisciplinary treatment (T 1) and at the 6-month follow-up (T 2)compared with the pretreatment status (T 0) (Tables 2 and 3). The pre j post comparisons revealed significant changes in VAS pain scores ( F 2,296 = 46.09, P e 0.0001). Medium effect sizes at T 1(d = j0.6) and T 2 (d = j0.7) indicate clinically relevant pain

relief. Significant changes in pain-related disability were observed after multidisciplinary treatment and at the 6-month follow-up( F 2,310 = 130.89, P e 0.0001), with a strong treatment effect (d = 0.8) at T 1, which remained almost stable at T 2 (d = 0.7).Functional capacity improved significantly at T 1 (71.46[19.35]) and at T 2 (73.72 [21.68]) ( F 2,251 = 29.93, P e 0.0001),with medium effect sizes between 0.4 and 0.5. Quality of lifeimproved at T 1 for physical function ( F 1,303 = 54.8, P e 0.0001),vitality ( F 1,247 = 41.15, P e 0.0001), and mental health ( F 1,247 =41.58, P e 0.0001). Treatment effects were moderate for physi-cal function and vitality (d = 0.5) and strong for mental health(d = 0.8) at T 1 and remained stable at T 2. The depression scoresindicated significant improvement at T 1 and at T 2, with mediumeffect sizes of d = 0.7.

Impact of Sociodemographic and Pain Covariateson Effect Sizes of VAS

To further analyze the impact of sociodemographic para-meters on therapy outcome, we evaluated effect sizes of subjective pain perception grouped by sociodemographic parameters of our study population (Table 4). Women displayed greater effect sizes than men did (j0.9). There were significantly greater effect sizes for the age group 30 to 39 years (j1) than for younger and older age groups. Further, married patients (j0.9), patients with a professional education (j0.7), and those with good job security(j0.9) benefited most. Interestingly, the impact of duration of sick leave seems to be U-shaped. Patients with short (G14 days)and long (96 weeks) durations of sick leave displayed higher

effect sizes (j

0.9 to 1.3) than those with 2 to 6 weeks. Patientswho wanted to negotiate a retirement plan had significantly lower effect sizes (0.3) than those who did not (j0.8).

Moreover, the impact of pain characteristics was evaluated.Patients with 1 pain location (j1) and those with lumbar pain(j0.9) displayed greater effect sizes than those with cervical pain or pain in both locations. An increase in number of painlocations (j0.7) and severity of accompanying pain (j0.7) in

other body areas significantly impaired therapy outcome and decreased VAS effect sizes. Stage of chronicity showed no sig-nificant impact on therapy outcome. Patients with duration of pain more than 2 years showed a poorer therapy outcome thanthose with shorter pain duration. Patients with low frequency of pain displayed the lowest treatment effect at T 2 (0.1).

DISCUSSIONIn this prospective longitudinal study, we aimed to examine

in detail the effectiveness of our multidisciplinary treatment pro-gram with regard to pain perception, functional capacity, and quality of life in patients with CLBP. Further, the impact of cov-ariates on therapy outcome was evaluated. By determining effect sizes, we enable a closer comparison of therapy outcome between

multidisciplinary treatment and other published treatment settings.Three hundred ninety-five patients with CLBP were in-

volved in this prospective cohort study, which was characterized by clearly defined inclusion and exclusion criteria, a standardized treatment setting, and analysis of different recommended outcome parameters.25 We conceptualized this study as a noncontrolled trial. Thus, there was no form of patient selection, and all con-senting patientsfrom our pain clinic whomet theinclusion criteria participated in the study. Regarding the demographic data, thestudy population was comparable with previous studies reportingon patients with CLBP.6,10,12,26

The multidisciplinary treatment approach resulted in sig-nificant benefits for patients by the end of the therapy, as shown by a significant improvement in all outcome measures. These

results remained stable at the 6-month evaluation. This displaysthat the improvements were not negated by normal-life conditions.Our results demonstrate the effectiveness of this multidisciplinary

TABLE 2. Outcome Variables at the 3 Assessment Time Points T 0, T 1 (End of Treatment), and T 2 (6-Month Follow-Up)

Outcome variables T 0 T 1 T 2 F P

VAS 51.8 (20.41) 39.2 (21.0) 37.4 (23.9) F 2,296 = 46.09 e0.0001

PDI-G 26.66 (12.30) 17.34 (12.03) 17.55 (14.15) F 2,310 = 130.89 e0.0001

FFbH-R 64.5 (19.1) 71.46 (19.35) 73.72 (21.68) F 2,251 = 29.93 e0.0001

SF-36 physical functioning 60.92 (19.9) 67.58 (22.36) 75.38 (37.36) F 1,303 = 54.8 e0.0001

SF-36 mental health 51.26 (16.30) 71.57 (18.59) 61.46 (7.65) F 1,247 = 41.58 e0.0001

SF-36 vitality 44.77 (19.02) 59.99 (19.78) 54.09 (20.04) F 1,247 = 41.15 e0.0001

CES-D 20.71 (11.98) 14.17 (4.84) 13.21 (10.95) F 3,257 = 100.53 e0.0001

TABLE 3. Cohen’s d Effect Sizes for Outcome Parametersat T 1 and T 2

Outcome Variables T 0 j T 1 d T 0 j T 2 d

VAS j0.6 j0.7

PDI-G 0.8 0.7

FFbH-R 0.5 0.4

SF-36 physical functioning 0.5 0.5

SF-36 mental health 0.8 0.8

SF-36 vitality 0.5 0.5

CES-D 0.7 0.7





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therapy program immediately after treatment (T 1

) and at the 6-month follow-up (T 2) compared with the pretreatment status (T 0). To highlight the different results for the various parameters and to demonstrate how they compared to oneanother, we computed within-group effect sizes as described above (Table 5). This strategy permits computation of standard-ized values for change based on dependent variables, even if datafrom a control group are not available.22 The effect of the treat-ment was established by the effect sizes (Cohen’s d ranging from0.4 to 0.8). According to the calculated effect sizes, treatment results were best with regard to pain-related disability, depres-sion scores, and mental health Y related quality of life. Overall,almost all effect sizes were medium or high, demonstrating that a multidisciplinary regimen is most effective in treating CLBP byincreasing patients’ activity, restoring physical functions, and

addressing psychological disorders.To analyze which type of patient benefits the most, we

further analyzed the impact of sociodemographic parameterson therapy outcome.27 To this end, we evaluated effect sizes of subjective pain perception grouped by sociodemographic para-meters and pain characteristics of our study population. Sex- and age-related differences of the treatment effect were shown, withlower effect sizes for patients older than 40 years. This is inaccordance with the study by Bucher et al.28 These researchersevaluated the impact of age on therapy outcome and found that patients in all age groups benefit from multidisciplinary therapy but with less improvement in those older than 35 years. Higher differences were shown for marital status and educational level.Job-related parameters seem to be relevant, with lesser effect

sizes for patients performing work with a pronounced physicalcomponent and those with lower job security. In accordance with

other studies, we showed that the desire for retirement and compensation significantly lowered the treatment effect.8,29 Y 31

Furthermore, the impact of pain characteristics was evalu-ated. Higher number of pain sites and greater severity of ac-companying pain in other body areas significantly impaired therapy outcome and effect sizes as assessed by VAS. This is inaccordance with previous studies by our group and other insti-tutions.32 Stage of chronicity did not show any significant impact on therapy outcome. We previous showed that also patientswith higher levels of chronicity improved significantly in alloutcome criteria. Thus, concluding that multidisciplinary ther-apy for CLBP should not be limited to patients in lower stages of chronicity.33 Although patients with a longer history of pain (92years) also benefit from multidisciplinary treatment, therapyoutcome was better in those with pain of shorter duration.

A number of studies have evaluated the outcome of mul-tidisciplinary treatment, but only a few have assessed the effect sizes.27,28,34 Y 38 Effect sizes are especially useful in enablingcomparison of the magnitude of experimental treatments fromdifferent settings. Pöhlmann et al.,35 investigating the efficacy of

a multidisciplinary treatment program for chronic pain, found effect sizes are comparable to our data, with significant improvement and medium to high treatment effects. Their programwas comparable to our treatment plan with high treatment in-tensity of 122 hours. Pfingsten et al.26 reported slightly higher effect sizes after multidisciplinary treatment in a comparablesetting, with effect sizes of 1.45 for pain intensity and 2.47 for pain-related disability. This might be due to differences in thestudy population because we did not limit the study population by age or duration of sick leave. In a quantitative meta-analysis by Keller et al.36 in 2007, pooled effect sizes were presented for nonsurgical treatments for CLBP. Low to moderate treatment effects were found for exercise therapy (0.13 Y 0.52) and behav-ioral treatment (pooled effect size, 0.57). This might be becausethe studies included mainly involved monodisciplinary treat-ments and, moreover, did not display high treatment intensity.Furthermore, invasive treatment options (transcutaneous elec-trical nerve stimulation, manipulation) were inferior regardingshort- and long-term treatment effects, with only small effect

TABLE 4. Evaluation of Sociodemographic Parameters onEffect Sizes for VAS at T 2

Variable VAS T 0 j T 2 Cohen’s d

Age, y 18 Y 29 j0.70

30 Y 39 j1.0

40 Y 49 j0.8

50 Y 63 j0.6

Sex Men j0.5

Women j0.9

Marital status Single j0.5

Married j0.9

Divorced j0.6

Educational level Low j0.5

Intermediate j1.1

High j0.7

Professional education Yes j0.7

No j1.1

Physical job exposure Low j0.9

Intermediate j0.8

High j0.5

Days of sick leave withinlast 6 mo

G14 d j0.9

2 Y 6 wk j0.5

6 Y 12 wk j0.9

912 wk j1.3

Present job certainty Yes j0.9

No j0.7

Desire for retirement Yes 0.3

No j0.8

TABLE 5. Evaluation of Pain Characteristics on Effect Sizes for VAS at T 2

Variables VAS T 0 j T 2 Cohen’s d

Pain location Lumbar j0.90

Cervical and lumbar j0.80

Stage of chronicity 1 j0.90

2 j0.90

3 j0.80

No. pain sites Single site j1

Two sites j0.9

Multiple sites j0.7

Duration of current pain e6 mo j1.1

6 Y 12 mo j1.1

1 Y 2 y j1.4

2 Y 5 y j0.4

95 y j0.4

Frequency of pain e1 times a day 0.1

Several times a day j1

Constantly j1

Accompanying pain Yes j0.7

No j1.2




https://www.researchgate.net/publication/6217835_Effect_sizes_of_non-surgical_treatments_of_non-specific_low-back_pain?el=1_x_8&enrichId=rgreq-fb6ec09e-7007-4c1b-9a47-7010d673e63a&enrichSource=Y292ZXJQYWdlOzIyMTgzMjMxNztBUzoxMDIxMTM2MTkyMTg0MzJAMTQwMTM1NzE5MjQyNg==https://www.researchgate.net/publication/6217835_Effect_sizes_of_non-surgical_treatments_of_non-specific_low-back_pain?el=1_x_8&enrichId=rgreq-fb6ec09e-7007-4c1b-9a47-7010d673e63a&enrichSource=Y292ZXJQYWdlOzIyMTgzMjMxNztBUzoxMDIxMTM2MTkyMTg0MzJAMTQwMTM1NzE5MjQyNg==https://www.researchgate.net/publication/6217835_Effect_sizes_of_non-surgical_treatments_of_non-specific_low-back_pain?el=1_x_8&enrichId=rgreq-fb6ec09e-7007-4c1b-9a47-7010d673e63a&enrichSource=Y292ZXJQYWdlOzIyMTgzMjMxNztBUzoxMDIxMTM2MTkyMTg0MzJAMTQwMTM1NzE5MjQyNg==https://www.researchgate.net/publication/6217835_Effect_sizes_of_non-surgical_treatments_of_non-specific_low-back_pain?el=1_x_8&enrichId=rgreq-fb6ec09e-7007-4c1b-9a47-7010d673e63a&enrichSource=Y292ZXJQYWdlOzIyMTgzMjMxNztBUzoxMDIxMTM2MTkyMTg0MzJAMTQwMTM1NzE5MjQyNg==


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sizes. A comprehensive review of multidisciplinary treatment for chronic pain by Scascighini et al.38 underlined the superior ef-ficacy of multidisciplinary treatment relative to standard medicaltreatment and other nonmultidisciplinary approaches. A comparison of different multidisciplinary programs did not revealany difference between settings; however, although only 4 of theincluded studies looked into this.

Our treatment plan is characterized by high treatment in-tensity, with a total of 120 hours during 3 weeks. Therapy pro-grams with at least 100 hours of treatment have yielded higher success rates than monodisciplinary treatments.36,39,40 Programswith less than 30 hours have proved ineffective.41 Smeets et al.37

recently performed a multicenter, randomized clinical trial of 172 patients with nonspecific CLBP to determine the effec-tiveness of 3 commonly used nonsurgical treatment approaches.These outpatient treatments were based on different theoreti-cal models of CLBP V the active physical model, the cognitive- behavioral model, and a combination of both V and were delivered 3 times a week during 10 weeks. The authors then compared patients treated with each of these therapeutic modalities with a

group of patients on the waiting list. At 6 months and 1 year after treatment, all 3 active treatments were more effective than notreatment, but no one treatment group showed more clinical benefit than the other two.37 The authors concluded that theseresults could, at least partially, be ascribed to the fact that exposureto the cognitive-behavioral treatment components was only 78hours and did not reach the 100 hours originally recommended byGuzmán et al.8 in a Cochrane review. These authors concluded that intensive multidisciplinary, biopsychosocial rehabilitationameliorates CLBP and improves physical functioning, whereasinterventions of less than 100 hours do not yield an additionaleffect compared with nonmultidisciplinary treatment or conven-tional care.

Treatment costs were, on average, €180 per day per patient,which results in an average total treatment cost of €3780 per patient. Published treatment costs of other institutes range from €90 to €300 per day per patient.35,40,42 It has to be taken intoaccount that costs of therapy are only a small proportion of allcosts associated with CLBP and that the major costs result fromloss of productivity, work absenteeism, and disablement.2,4 Arecent study by Jensen et al.42 could demonstrate that multidis-ciplinary treatment significantly reduces sickness absence even7 years after therapy. The estimated cost reduction was more than €90,000 per referred patient.

One important limitation of the study is the missing controlgroup. On the basis of ethical considerations a randomized con-trol group (e.g., with lower treatment intensity) was not realized because all our patients experienced severe forms of CLBPfor which standard treatment with lower treatment intensity has

already failed. Other studies have included a waiting list controlgroup, which would have been an appropriate solution for our study design.23,40,42 Because the design of this study was un-controlled, it remains to be demonstrated that the outcomeresults were based predominantly on treatment procedures rather than confounding variables or simply the influence of time. Ameta-analysis by Flor et al.22 included 11 controlled studies and demonstrated that the return-to-work rate for patients under-going multidisciplinary treatment for CLBP was 67% compared with 24% in the control group. This was further confirmed byDemoulin et al.40 in a comparable treatment setting. However,the fact that the patients displayed a mean pain duration of 16months without any improvement before multidisciplinary treat-ment is a strongindicator that time did not play a predominant role

in determining improvement. Furthermore, the maintenance of the positive treatment effects during a period of 6 months argues

against placebo effects. On the other hand, the relevance of other confounding variables such as encouragement by the profes-sionals and enthusiasm for the program may have influenced treatment outcome. Thus, longer follow-up times are necessary to prove the long-term effect of this treatment and to verify if treat-ment effects remain stable without the support of treatment pro-viders and after the initial enthusiasm and excitement of patientshas faded. Sociodemographic, clinical, and psychological para-meters of the study population need to be taken into account whendiscussing generalizability and reproducibility of our results. Adetailed assessment of these parameters (e.g., depression score, pain catastrophizing score) is vital to define confounding var-iables. Moreover, apart from patient parameters, a number of factors on the side of the treatment providers, for example, inter-disciplinary agreement on treatment organization, attitude, and approach of the professionals, may have a significant impact ontherapy outcome but are hard to identify and measure. Further studies are necessary to evaluate which specific intervention isresponsible for treatment outcome.

In summary, comparisons with other treatments seem to

indicate that the intensity, duration, and frequency of a multi-disciplinary treatment program may be the most important fac-tors in its success. In this regard, it has to be taken into account that a number of studies analyze a multicomponent treatment rather than a multidisciplinary approach owing to a lack of in-terdisciplinary coordination. Future studies need to evaluatewhich features are responsible for improvement with the goal of individualizing treatment settings and addressing the variabil-ity of patients’ needs. A tailored treatment setting could help toreduce treatment costs and eventually reduce treatment dura-tion. Adherence to internationally defined standards is neces-sary to increase homogeneity of treatment settings and improvecomparability.

CONCLUSIONSThe results of this longitudinal not controlled cohort study

confirmthat multidisciplinary pain therapy significantly improves pain, return-to-normal function, and some aspects of health-related quality of life even for patients with a long history of chronic back pain, with stable treatment effects at the 6-monthfollow-up. Effect sizes are higher than for monodisciplinary treat-ments and comparable with those of other therapies with hightreatment intensity. Treatment results were highest in conjunctionwith pain-related disability, mental health-related quality of life,and CES-D scores. Overall, almost all effect sizes were moderateto high, demonstrating that a multidisciplinary regimen is most effective in treating CLBP by increasing patients’ activity, restor-ing physical functions, and addressing psychological disorders.

These treatment settings are vital for the treatment of patients withCLBP. We emphasize the presentation of effect sizes to improvecomparison of different treatment settings across disciplines. Thiscould help to determine which components of the treatment set-ting matter most to further tailor treatment to the patients’ needs.

REFERENCES

1. Badley EM, Rasooly I, Webster GK. Relative importance of

musculoskeletal disorders as a cause of chronic health problems,

disability, and health care utilization: findings from the 1990 Ontario

health survey. J Rheumatol . 1994;21:505 Y 514.

2. Van Tulder MW, Koes BW. Chronic low back pain and sciatica.

Clin Evid . 2002;7:1032 Y 1048.

3. Kohlmann T. Musculoskeletal pain in the population. Schmerz .2003;17:405 Y 411.




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8/8

4. van Tulder MW, Koes BW, Bouter LM. A cost-of-illness study of

back pain in The Netherlands. Pain. 1995;62:233 Y 240.

5. Hicks GS, Duddleston DN, Russell LD, et al. Low back pain.

Am J Med Sci. 2002;324:207 Y 211.

6. Van der Hulst M, Vollenbroek-Hutten MMR, IJzerman MJ.

A systematic review of sociodemographic, physical, and psychological predictors of multidisciplinary rehabilitation- or, back school

treatment outcome in patients with chronic low back pain. Spine.

2005;30:813 Y 825.

7. Karjalainen K, Malmivaara A, van Tulder M, et al. Multidisciplinary

biopsychosocial rehabilitation for subacute low back p ain in

working-age adults: a systematic review within the framework of the

Cochrane Collaboration Back Review Group. Spine. 2001;26:262 Y 269.

8. Guzmán J, Esmail R, Karjalainen K, et al. Multidisciplinary

bio-psycho-social rehabilitation for chronic low back pain.

Cochrane Database Syst Rev. 2002;CD000963.

9. Cairns D, Mooney V, Crane P. Spinal pain rehabilitation: inpatient

and outpatient treatment results and development of predictors for

outcome. Spine. 1984;9:91 Y 95.

10. Guzman J, Esmail R, Karjalainen K, et al. Multidisciplinaryrehabilitation for chronic low back pain: systematic review. BMJ .

2001;322:1511 Y 1516.

11. Van Tulder MW, Koes B, Malmivaara A. Outcome o f non-invasive

treatment modalities on back pain: an evidence-based review. Eur Spine

J . 2006;15(Suppl):64 Y 81.

12. Patrick LE, Altmaier E, Found EM. Long-term outcomes in

multidisciplinary treatment of chroniclow back pain: results of a 13-year

follow-up. Spine. 2004;29:850 Y 855.

13. Jensen IB, Bergström G, Ljungquiat T, et al. A 3-year follow-up of a

multidisciplinary rehabilitation program for back and neck pain.

Pain. 2005;115:273 Y 283.

14. Airaksinen O, Brox JI, Cedraschi C, et al. European guidelines for the

management of chronic nonspecific low back pain. Eur Spine J .

2006;15(Suppl 2):192 Y

300.15. Gatchel RJ, Mayer TG. Evidence-informed management of chronic low

back pain with fun ctional restoration. Spine J . 2008;8:65 Y 69.

16. Chibnall JT, Tait RC. The pain disability index: factor structure and

normative data. Arch Phys Med Rehabil . 1994;75:1082 Y 1086.

17. Tait RC, Chibnall JT, Krause S. The pain disability index: psychometric

properties. Pain. 1990;40:171 Y 182.

18. Kohlmann T, Raspe HH. Der Funktionsfragebogen Hannover zur

alltagsnahen Diagnostik der Funktionsbeeinträchtigung durch

Rückenschmerzen (FFbH-R). Rehabilitation. 1996;35:1 Y 8.

19. Ware JE, Sherbourne CD. The MOS 36-item short form health survey

(SF-36). Med Care. 1992;30:383 Y 473.

20. Radloff LS. The CES-D scale: a self-report depression scale for

research in the general population. Appl Psychol Meas.

1977;3:385 Y 401.

21. von Korff M, Ormel J, Keefe FJ, et al. Grading the severity of chronic

pain. Pain. 1992;50:133 Y 149.

22. Flor H, Fydrich T, Turk DC. Efficacy of multidisciplinary pain treatment

centers: a meta-analytic review. Pain. 1992;49:221 Y 230.

23. Cohen J. A power primer. Psychol Bull . 1992;112:155 Y 159.

24. Keppel G, Wickens TD. Design and Analysis: A Researcher’s

Handbook . 4th ed. Englewood Cliffs, NJ: Prentice-Hall; 2004.

25. Bombardier C. Outcome assessments in the evaluation of treatment of

spinal disorders: summary and general recommendations. Spine.

2000;25:3100 Y 3103.

26. Pfingsten M, Hildebrandt J, Leibing E, et al. Effectiveness of a

multidisciplinary treatment program for chronic low-back pain. Pain.

1997;73:77 Y 85.

27. van Hooff ML, van der Merwe JD, O’Dowd J, et al. Daily functioningand self-management in patients with chronic low back pain after an

intensive cognitive behavioral program for pain management. Eur Spine

J . 2010;9;19:1517 Y 1526.

28. Buchner M, Neubauer E, Zahlten-Hinguranage JA, et al. Age as a

predicting factor in the therapy outcome of m ultidisciplinary treatment

of patients with chronic low back pain Y a prospective longitudinal

clinical study in 405 patients. Clin Rheumatol . 2007;26:385 Y 392.

29. Bendix AF, Bendix T, Haestrup C. Can it be predicted which patients

with chronic low back pain should be offered tertiary rehabilitation

in a functional restoration program? A search for demographic,

socioeconomic, and physical predictors. Spine. 1998;23:1775 Y 1783.

30. Fredrickson BE, Trief PM, Van Beveren P, et al. Rehabilitation

of the patient with chronic back pain, a search for outcome predictors.

Spine. 1988;13:351 Y 353.

31. Gallagher RM, Rauh W, Haugh LD, et al. Determinants of

return-to-work among low back pain patients. Pain. 1989;39:56 Y 67.

32. Moradi B, Zahlten-Hinguranage A, Barié A, et al. The impact of pain

spread on the outcome of multidisciplinary therapy in patients with

chronic musculoskeletal pain V a prospective clinical study in 389

patients. Eur J Pain. 2010;14:799 Y 805.

33. Buchner M, Neubauer E, Zahlten-Hinguranage A, et al. The influence of

the grade of chronicity on the outcome of multidisciplinary therapy

for chronic low back pain. Spine (Phila Pa 1976). 2007;32:3060 Y 3066.

34. Schütze A, Kaiser U, Ettrich U, et al. Evaluation of a multimodal

pain therapy at the University Pain Centre Dresden. Schmerz .

2009;23:609 Y 617.

35. Pöh lmann K, Tonhauser T, Joraschky P, et al. The Dachau

multidisciplinary treatment program for chronic pain. Efficacy data of adiagnosis-independent multidisciplinary treatment program for back

pain and other types of chronic pain. Schmerz . 2009;23:40 Y 46.

36. Keller A, Hayden J, Bombardier C, et al. Effect sizes of non-surgical

treatments of non-specific low-back pain. Eur Spine J . 2007;16:

1776 Y 1788.

37. Smeets RJ, Vlaeyen JW, Hidding A, et al. Ch ronic low back pain:

physical training, graded activity with problem solving training, or both?

The one-year post-treatment results of a randomized controlled trial.

Pain. 2008;134:263 Y 276.

38. Scascighini L, Toma V, Dober-Spielmann S, et al. Multidisciplinary

treatment for chronic pain: a systematic review of interventions and

outcomes. Rheumatology. 2008;47:670 Y 678.

39. Van Tulder M, Koes B, Bombardier C. Low back pain. Best Pract Res

Clin Rheumatol . 2002;16:761 Y 775.

40. Demoulin C, Grosdent S, Capron L, et al. Effectiveness of

a semi-intensive multidisciplinary outpatient rehabilitation program in

chronic low back pain. Joint Bone Spine. 2010;77:58 Y 63.

41. Mirza SK, Deyo RA. Systematic review of randomized trials

comparing lumbar fusion surgery to nonoperative care for treatment

of chronic back pain. Spine. 2007;32:816 Y 823.

42. Jensen IB, Busch H, Bodin L, et al. Cost effectiveness of two

rehabilitation programmes for neck and back pain patients: a seven year

follow-up. Pain. 2009;142:202 Y 208.


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J Clin Rheumatol 2012 Moradi01.03.2012.pdf

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