Efficacy of inpatient rehabilitation for chronic back pain in Germany: a systematic review 1980-2001

Abstract

Chronic back pain has a high personal impact, is frequent and of outstanding economical relevance. Analysis of the international literature indicates strong or moderate evidence for the effectiveness of multimodal multidisciplinary team care of chronic back pain. Our review aims at a complete review and critical appraisal of German studies of inpatient medical rehabilitation. We conducted a systematic search for relevant German studies (1/1980 - 6/2001) using electronic data bases, manual search of congress abstracts and postal questionnaires of 712 German rehabilitation clinics. Relevant studies were categorized according to the recommendation of the Cochrane Back Review Group. For all studies, aims, participants, type of intervention, evaluation time, main outcomes and results were extracted and tabulated. The effect size for 6 central outcome parameters (pain intensity, functional status, catastrophizing, depression, vitality, days on sickness leave) were calculated using pre-post comparisons and were integrated into short and long term weighted means of intra-group effect sizes. 30 studies, both controlled and uncontrolled, report a multitude of positive changes with inpatient rehabilitation treatment. Improvements included both somatic and psychological parameters. However, methodological quality was often poor; only three studies fulfilled the criteria for high quality. Comparison of meta analyses of German and international studies indicates partly good agreement (e. g. changes in pain intensity), partly discrepancies (e. g. functional ability in daily activities). Taken together, inpatient rehabilitation treatment for chronic low back pain in Germany appears to be of low to moderate efficacy. In the era of evidence based medicine, inpatient rehabilitation has to show its usefulness, necessity and efficiency as any other type of health care. For the German system of inpatient rehabilitation of chronic back pain available evidence is not conclusive, due to a lack of randomised controlled studies. The prevailing design of observational cohort studies has severe limitations in proving a causal relationship between outcomes and intervention. The international literature however provides more valid evidence in favour of the multimodal multidisciplinary intervention in chronic back pain. Under the assumption of a "class effect" of medical rehabilitation the German data seem to corroborate the conclusions drawn from international studies.