OBJECTIVE: To compare the long-term effectiveness of an integrated rehabilitation programme with an existing rehabilitation programme, in terms of back-specific disability, in patients with chronic low back pain.
DESIGN: A single-centre, pragmatic, two-arm parallel, randomised controlled trial.
SETTING: A rheumatology rehabilitation centre in Denmark.
SUBJECTS: A total of 165 adults (aged ? 18 years) with chronic low back pain.
INTERVENTIONS: An integrated programme (a pre-admission day, two weeks at home, two weeks inpatient followed by home-based activities, plus two 2-day inpatient booster sessions, and six-month follow-up visit) was compared with an existing programme (four-week inpatient, and six-month follow-up visit).
MAIN MEASURE: The primary outcome was disability measured using the Oswestry Disability Index after one year. Secondary outcomes included pain intensity (Numerical Rating Scale), pain self-efficacy (Pain Self-Efficacy Questionnaire), health-related quality of life (EuroQol-5 Domain 5-level (EQ-5D)), and depression (Major Depression Inventory). Analysis was by intention-to-treat, using linear mixed models.
RESULTS: 303 patients were assessed for eligibility of whom 165 patients (mean age 50 years (SD 13) with a mean Oswestry Disability Index score of 42 (SD 11)) were randomly allocated (1:1 ratio) to the integrated programme (n = 82) or the existing programme (n = 83). The mean difference (integrated programme minus existing programme) in disability was -0.53 (95% CI -4.08 to 3.02); p = 0.770). No statistically significant differences were found in the secondary outcomes.
CONCLUSION: The integrated programme was not more effective in reducing long-term disability in patients with chronic low back pain than the existing programme.
|Rehab Clinician (OT/PT)|
At the end of the day, it seems that the differences between the diverse multidisciplinary rehabilitation programmes in chronic low back pain don´t matter.
In the world I work in there is no availability of beds for inpatient management of back except for surgical cases. The study is relevant to the discipline but not to my clinical world.
It is a very well described and discussed study, of a high prevalent disability disease and of importance in primary care. It confirms the necessity to broaden the focus about the optimal way to deliver a multidisciplinary rehabilitation programme for these kind of patients, no limited to their most obvious medical aspects.
This is a comparison of two back pain rehab programmes - one 'integrated' and the other existing - both having inpatient elements. The outcomes are the same!
I found the conclusion particularly noteworthy, urging a broader perspective on management of CLBP rather than constantly introducing new interventions.
I’m shocked that inpatient care is an option in some parts of the world for chronic back pain when such a huge body of evidence is pointing towards not medicalising this group of patients. It would have been a more useful study to have had a 3rd arm with outpatient care or self directed management only.
This is a well constructed RCT demonstrating that difference models of care does not necessarily lead to different outcomes. It would be interesting to see if the program with a standardized "control" would see any difference between the 2 options.