Implementierung verhaltensmedizinischer Ansätze in der stationären orthopädischen Rehabilitation

Chronic low back pain represents a major health problem, especially in Western Europe and North America. Besides individual suffering, back pain is associated with substantial economical and societal costs (e.g., direct costs due to extensive use of medical health care, high indirect costs due to sick leave). Effective disability prevention strategies and effective treatments are therefore important and necessary. Meta-analyses provide strong or moderate evidence for the effectiveness of multidisciplinary interventions for chronic back pain combining physical, psychological and social treatment elements. However, there is still a lack of high quality studies in natural settings, especially with a randomised controlled study design. Against this background, the present study focuses on the implementation of behavioural-medical interventions in orthopaedic inpatient rehabilitation. In a randomised con¬trolled study, three relevant aspects were investigated. The aim of the first study was to investigate whether additional psychological interventions in the context of multidisciplinary inpatient pain treatment increases treatment efficacy compared to normal orthopaedic rehabilitation. In addition, we aimed to demonstrate the additional benefit of a subsequent maintenance program in further stabilising treatment successes. In accordance with previous meta-analyses, the multidisciplinary treatment was effective in improving core outcome measures in chronic back pain patients in the short term and the long term. Significant advantages in favour of behavioural-medical interventions were found on almost all pain coping strategies compared to traditional orthopaedic rehabilitation. However, the superiority of the multidisciplinary treatment was not as general as expected, because normal orthopaedic rehabilitation was inherently very effective in causing improvements in pain-specific variables. We found only slight advantages for the behavioural-medical treatment with subsequent booster sessions compared with the condition without a further maintenance program. The aim of the second study was to investigate at which point in time during the rehabilitation process patients with short-term versus long-term sick leave after an inpatient rehabilitation treatment differ. Surprisingly, both groups improved comparably during treatment, thus no specific treatment failures were found in the later long-term sick leave group. The long-term sick leave group deteriorated on most of the variables at follow-up (self-efficacy, perceived disability, occupational ambition, mental balance, and physical and mental health status), whereas the short-term sick leave group maintained the improvements reached during treatment. It is concluded that rehabilitation interventions should not only focus on inpatient treatment but also on the follow-up interval in order to prevent relapses and maintain success reached during treatment. Effective and stabilising aftercare approaches are required. Self-efficacy is associated with core variables in chronic pain patients. The aim of the third study was, therefore, to present the German adaptation of a questionnaire for the assessment of pain self-efficacy (FESS). This questionnaire has good psychometric properties and has predictive value. Additionally, the FESS is sensitive to changes. Therefore, the FESS seems to be a valid instrument for the evaluation of therapeutic success in the context of pain research. Altogether, the present study makes an important contribution to the evaluation of multidisciplinary pain treatment within the scope of a study with high methodological quality. The results show that the implementation of behavioural-medical interventions to orthopaedic inpatient rehabilitation is promising. Furthermore, the results provide information how to improve treatment efficacy for chronic pain patients (e.g., development of effective aftercare approaches). The results are finally discussed against the background of the strengths and shortcomings of the study.