腰痛治療の概念と成果 : 機能重視型治療vs.疼痛緩和型治療

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Function-

VersusPain-Centred

Concepts

and

Treatment

of

Low

Back

Pain:

Outcome

*

Peter

R,OESCH,MSc,

PT

**

Ab$tract

Return

to

work

is

the

primary

goal

in

the

treatment

of

patients

with

low

back

pain.

Treatment

can

be

pre-scribed on

the

base

of a

biomechanical

model assuming

that

a

physical

pathologic

condition

leads

to

pain

and

disability.

It

empleys a

"Pain-Centered

Treatment"

(PCT)

administering various measures of

pain

therapy.

The

bTopsychosocial

model acknowledges

the

role of

psychological

and social

factors

as well as

physical

factors

lead-ing

to

permanent

disability.

On

the

base

of

this

model

"Function-Centered

treatment"

_(FCT}

emphasizing

improve-ment

in

function

and not

primarily

pain

relief were

developed

to

facilitate

return

to

work.

It

remains unelear

whether

treatment

based

on

the

biornedical

rnodel with

its

restrictive recommendations

is

more effective

in

reducing work absenteeism

than

treatment

applying the

biopsychosocial

model

_primarily

emphasizing activity.

We

conducted a randomized controlled trial

in

Switzerland

in

_patients

with sick

leave

due

to

non-specific

non-acute

lew

_back

_pain

_(LBP)

_to

evaluate

the

effect of

three

weeks of

function-centered

compared with

pain-cen-tered

in-patient

rehabilitationi'2).

Inclusion

Criteria

were >6 weeks out of work

due

to

chronic non-specific

LBP.

174

_patients

were

included:

mean sick

leave

was

6.5

months,

Groups

were comparable at

baseline.

Results

FCT

vs

PCT:

at

discharge

seff-efficacy +5.9

_points

vs,

-7.4

_points

(ES

=

O,55,

_p

=

O.O03),

lifting

_capacity +2.3

kgs

vs.

+O.2

_kgs

(ES

=

O.54,

_p

=

O,O04}:

_after

3

_months

days

_{at work were}

25,9

_vs

15.8

{ES

=

O.36,

_p

=

O.029}:

_after

12

month

days

at work were

118

vs

74

(ES

=

O.35,

_p

=

O.Oll),

From

these

findings

we can conclude

that

FCT

is

more effective

than

PCT

for

increasing

work

days.

Key

word$ I

low

back

_pain,

return

to

work, exercise

therapy,

randemized controEled

trial

lntroduction

Bacaground

Low

back

pain

(LBP)

has

become

a major

health

_preblem

in

all

developed

countries, causing an

increase

in

sickness absence, rehabilization allewances and

disability

_pensions3),

The

increasing

rate of

disability

due

to

chronic

low

back

pain

(CLBP)

has

led

to

an explosion

in

costs4).

60-75%

of

the

total

medical and

indirect

costs of

LBP

can

be

attributed

to

the

_people

disabled

due

to

CLBP5).

In

Switzerland

the

num-ber

of

pensioners

in

the

last

ten

years

has

grown

annually

by

an average of

3.5%6),

Musculoskeletal

disorders

including

CLBP

were one of

the

two

causes

for

disability

with

the

biggest

annual

growth

and are, at

31%,

the

second

largest

***mde'iftasodikt

_ntm

_:

_{scAegzawiftut}

vs.v4fimemagiaff

Correspondence:

Peter

R.

Oesh,

MSc,

PT

Rheuma-

und

Rehabilitationszentrum

Valens,

CH-7317

SwitzerLand

{e-mail/

[email protected])

Valens,

reason

to

receive a

disability

pension7),

Dicrgnosis

of

Low

Back

Pain

Only

a

few

_patients

have

_{pathoanatomically}

well-defined

diseases,

Known

causes

for

specific

back

pain

are vertebral

fracture,

tumour,

infectTon,

inflammatory

diseases,

nerve root compression, spondylolysthesis, spinal stenosis and

definite

instability8}.

Evidence

suggests

that

fewer

than

15%

of

indi-viduals with

back

pain

can

be

assigned

to

one of

these

spe-cific

back

pain

categories9),

In

the

remaining

85%

of

patients

with

back

pain

a specific

diagnosis

is

impossibie.

This

has

led

to

a wide

diversity

of syndromes

depending

heavily

on

the

individual

physicianiO),

Patients

with

back

pain

are

like-ly

to

receive'different

labels

from

different

specialists, such as

diagnosis

of

degenerative

disc

disease,

facet

syndrome,

instability,

and sacroiliac

paTn,

There

is

little

scientific

evi-dence

for

establishment ofmany of

these

diagnostic

Iabelsii),

Besides

the

history

and

physical

examination of

patients

with spinal

_problems,

radiological examinations are

frequently

Function-

Versus

Pain-Centred

Treatment

of

usedi2).

However,

the

frequent

use of radiography

is

not

jus-tified

by

the

eutcome.

No

causal relationship

between

radi-ographic

findings

and non-specific

low

back

pain

has

been

foundi3).

Guidelines

for

7}'eatnzent

of

IVbn-Specific

Low

Back

Pain

The

failure

of modern medicine

to

diagnose

the

anatomi-cal structure causing

low

back

pain

and

to

relieve

pain

and

disabllity

in

chronic

pain

patients

has

led

to

a

different

treat-ment approach

in

the

past

two

decades,

Two

major reviews

concluded

that

Return-To-Work

and not

pain

relief must

be

the

_primary

goal

in

treatment

of chronic

back

pain

patientsi4).

The

Paris

Task

Force

Report

found

consistent scientific evidence

in

more

than

a

dozen

experimental

ran-demized

studies

for

pregrammes

combining stretching,

strength and

fitness

training

reducing

the

duration

of

back-pain-related

incapacity,

Hewever,

a

detailed

analysis of

these

artlcles

indicated

that

they

generally

provided

inadequate

descriptions

of

how

activity

is

prescribed

to

patients

who

have

back

pain.

The

authors concluded,

'`it

appears

that

the

key

to

success

is

physical

activity

itself

-i.e,

activity of any

form-

rather

than

any specific activity''i4).

Pain-Centred

Vlersus

Funetion-Centred

Z'eatment

Physical

activity can

be

prescribed on

the

base

of a

bio-mechanical medel

or

a

biopsychosocial

treatment

approach.

The

(traditional)

biomechanical

model of

disease

mainly

focus-es on somatic

Tssues.

It

is

based

on the

idea

that a

physi-cal

pathologic

condition

leads

to

_pain

and

disability.

Clinical

recognition and

cliagnosis

of

the

underlying

pathologic

cen-dition

prevides

the

basis

for

rational

_physical

treatment

of

the

illnessi5).

This

model

is

refiected

in

the

frequentiy

restric-tive

recommenclations of

physicians

regarding activity and worki6).

In

order

to

control

pain,

various measures of

pain

therapy

such as

trigger

point

massage, acupuncture,

physi-cal

treatment

_(e,g.

electrotherapy,

balneetherapy)

are

pre-scribed.

Exercise

therapy

is

administered

but

pain

intensity

is

used as a

guideline

to

determine

the

intensity

of

the

exer-cises,

A

biomechanical

approach

like

this

may

lead

to

overt

pain

behaviouri5).

The

biopsychosocial

model

developed

more recently acknowledges

that

other

factors

than

tissue

damage

and

resulting

_pain

are responsible

for

permanent

disability.

It

emphasizes the role of

psychological

factors

such as

personal

beliefs,

illness

behaviour

and

fear

avoidance as weli as social

facters

such as

family,

work and wider social network

in

the

development

and maintenance of syrnptomsi7),

On

the

base

of

this

model werk

hardening

programmesiS)

and

func-tional

restoration

programmesig)

emphasizing

improvement

in

function

and not

primarily

pain

relief were

developed

with

the

intention

of overcoming

the

dysfunctional

illness

behav-Low

Back

Pain:

_Concepts

and

Outcome

329

iour

and

implementing

ergenomic and social

intervelltions

to

facilitate

return

te

work,

What

is

the

Evtdence

ofExercise

to

Achieve

Return

to

Wbrke

Until

the

end of

the

20th

century

there

was contradicto-ry evidence whether vocational outcomes can

be

improved

by

exercises or an

intensive

multidisciplinary

bio-psychoso-cial

intervention2e'22).

However,

two

recently

published

meta-analyses

found

strong evidence

that

sick

days

can

be

reduced

by

exercise23'24),

One

study

found

that

93%

_(14f15)

of

the

RCTs

investigated

were

performed

in

Scandinavia

and

concluded

that

further

research

is

needed

in

other

coun-tries24).

It

also remains

unciear

whether

treatrnent

based

on

the

biomedical

model with

its

restrictive recommendations

is

more effective

in

reducing work absenteeism

than

treat-ment applying

the

biopsychosocial

model

primarily

empha-slzmg actlvlty.

In

view ef

these

findings

we conducted a randomized

con-trolled

trial

in

Switzerland

in

patients

with sick

leave

due

to

non-specific non-acute

LBP

to

evaluate

the

effect of

three

weeks of

function-centered

compared with

_{pain-centered}

in-patient

rehabilitationJ'2).

Methods

lnclusion

Criteria

and

Randomization

Patients

were

eligible

if

they

were

between

20

and

55

years of age,

had

at

least

6

weeks of sick

leave

during

the

previeus

6

menths

due

to

non-acute non-specific

LBB

and

had

suficient

knowledge

of

German

or

Italian

to

follow

the

instructions

during

the

physical

assessment,

Not

eligible

were

_patients

with cardievascular,

pulmonary

or

psychiatric

disease

or other comorbidity

that

would reduce working capacity.

A

rheumatologist

determined

the

eligibitity of

patients.

Based

on

the

results of an earlier study,

four

pre-dTctive

tests

fer

non-return

to

work were used and

patients

with

two

or more

positive

predictive

tests

were excludecl25).

Patients

were

included

between

January

200e

and

May

2003.

The

study was approved

by

the

ethical committee of

the

canton of

St

Gallen.

7}'eatment

All

patients

were

treated

six

days

per

week and

the

length

of stay considered necessary was three weeks.

Independent

teams

of

therapists

were responsible

for

the

two

different

treatments.

Function-Centered

Treatrnent

_as71)

All

patients

were

treated

by

a rheurnatologist, a

physical

and eccupational

therapist

trained

in

ergonemics, a sperts

therapist,

a soclal worker and a nurse.

If

required, a

NII-Electronic Library Service

330

mp\fiide\

was

based

on work

hardening

and

functional

restoration

grams.

The

_primary

_goal

in

the

FT-group

ef

4

hrsfday

was

to

increase

work-related capacity.

Treatment

emphasized

improving

self-efficacy,

defined

as the

_patients'

confidence

in

their ability to carry out normal activities of

daily

living.

The

rheumatologist

informed

_patients

about

the

results of

the

imaging

and other

diagnostic

precedures

as well as about

the

benign

character of non-specific

LBP.

Patients

were

told

that

degenerative

changes,

if

diagnosed,

were within

the

mal range

(e,g.

not causing

pain

in

the

majority of

persons).

The

therapist

performed

a werk-related assessment

ing

of a

job

profile

describing

the

physical

demands

and an

evatuation of

the

iob-relevant

physical

activities suclt as

lifV

ing

and carrying

loads,

working

in

a

bent

_position

or

forming

overhead activities.

Activities

for

treatment

were

chosen

based

on

the

_patient's

required

capacities

idennfied

in

the

work-related assessment.

Treatment

consisted of werk

simulation, strength and endurance

training

through

netic exercise, cardiovascular

training

performed

by

walking

and aqua-aerobics, sports

therapy

and self-exercise,

Patients

were

told

that

increasing

activity might cause mere

_pain

because

the

body

had

to

_get

used

to

the activity again.

All

team

members emphasized

that

patients

should eontinue

therapeutic

aetTvities even

if

pain

increased.

The

treatment

protocol

did

not contain massage,

hot-packs

and other

sive

treatments

because

these

therapies

were not considered

to

facilitate

an

increase

in

activity and selfeficacy, nor

do

the

literature

prove

them

effective.

'

Pain-Centered

TVeatment

(Pav

All

patients

were

treated

by

a rheumatologist, a

_physical

therapist

and a nurse.

If

required, a

psychologist

or a social

worker was consulted.

The

primary

goal

in

the

tered

treatment

_group

{PT-group}

was

to

reduce

pain,

The

secondary

_goal

was to

increase

strength and

decrease

ability.

The

_{physiotherapist}

_performed

a

physical

tion to

identify

_painful

movements and

limitations

in

ity,

strength and muscle

length

in

the

lumbar

region and

lower

extremities,

The

duratien

of

treatment

was

2

if2

hrsfday

and eonsisted of

individually

selected

passive

and

active mobilization, stretching, strength

training

and a mini

back-schoeL

Contrary

to

the

FT-group,

patients

in

the

group

were

teld

to

step activities when

pain

increased.

Passive

pain

modulating

treatments

such as

hot

_packs,

trotherapy

or massage were used

daily,

Low

intensity

movement

therapy

in

the

_pool

and

progressive

muscle

ation

further

enhanced relaxation,

Progressive

muscle

ation used systematic contraction and relaxation of specific

muscle

_groups,

Patients

were encouraged

to

incorporate

relaxation

techniques

into

daily

Iiving

as a coping skill

to

reduce stress, muscle

tension

and

pain.

ce34kce8e

Outcome

Mbasurements

A

blinded

research assistant

(MR)

recorded the

work-relat-ed

predictive

factors

and

performed

the

physieal

measure-ments

before

and after rehabilitation.

The

research assistant

was not

involved

in

any

_patient

treatment

in

the

rehabi]i-tation

center.

Assessments

were

performed

in

a separate

room to

prevent

unmasking of

the

assessor.

Patient

ques-tionnaires

were used

to

assess self-efficacy, satisfaction with

treatment

and

pain.

Patients

eould not

be

blinded

to

treat-ment

but

allefforts were

taken

to

keep

patients

unaware of any expected advantage

in

effectiveness, a condition

that

is

sometimes called `naive',

PrimaTv,

Outeome

The

number of

days

at work was the

primary

outcome,

Each

calendar

day

within

a

_period

at work was counted,

leading

te

a maximum of

90

days

at work

during

the

3-month

follow-up

_period,

This

method

is

insensitive

to

the

fact

that

patients

work at

different

days

of

the

week.

Because

a central

database

recording sick

leave

does

net

exist

in

SwTtzerland,

we assessed

days

at work with

ques-tionnaires

sent

to

the employer and

the

primary

physician

after

three

months.

Inconsistencies

were solved

by

additional

phone

callswith

the

persons

involved.

SecondaT),

Outcomes

Self-efficacy,

defined

as

the

patients'

confidence

in

their

ability

to

carry out normal activities of

daily

living,

was

assessed

before

and after

treatment

with

the

Performance

Assessment

and

Capacity

Testing26).

Befere

and after

the

rehabilitation,

the

maximum

lifting

capacity was assessed

from

fioor

to waist,

from

waist to crown and

horizontally

en waist

level,

The

research

assis-tant

was

trained

and experienced

in

this

method and

the

reliabiiity

has

been

confirmed27'29).

The

perceived

effect was assessed after

treatment

and after

three

months with a

questionnaire

covering

physical

capacity,

general

well-being and overaU

improvement.

We

used a

7-point

Likert

scale30).

Mementary,

maximal and minimal

pain

during

the

last

week was rated on an

11-point

Numeric

Rating

Scale

rang-ing

from

O,

`no

pain',

to

10,

`the

worst

pain

I

can

imagine'.

Pain

measurements were

taken

before

and after

treatment

as well as after

three

months,

Before

and after

treatment

the

following

_physical

mea-surements were

performed.

The

finger

to

fioor

distance

was used as a measure of active spinaL and

hip

mobility

in

fiex-ion3i),

Spinal

mobility

in

extension was measured

in

degrees

with an

inclinometern2).

Muscle

performance

was assessed

by

recording

the

maximum

duration

of

isometric

hip

and

trunk

extension and

flexion

against

gravity33),

Functien-

Versus

Pain-Centred

Treatment

Table

1

Comparability

of

the

of

Low

Back

Pain:

Treatment

Groups

Concepts

and

Outcome

at

Baseline

331

Function-centered

treatment

group

{n=87)

Pain-centered

treatment

group

(n=87)

Age

(SD}

Gender

(men!women)

Body

Mass

Index

(SD)

Nationality

Switzerland

Italy

Yugoslavia

Bosnia

Macedonia

Croatia

Spain,

Pertugal,

Turkey

Unemployed

CN,

%)

Heavy

work:

DOT

>

3

_{N,

%}

No

professional

education

(N,

%}

Mean

days

of sick

leave

during

2

years

before

treatment

Seff-efficacy

(PACT,

SD)

Lifting

capacity

(kg,

SD}

floor-waist

horizontal

waist-shoulders

Pain

_(NRS

O-10,

SD}

Muscle

performance

(sec.

SD)

Back

extension

Flexion

Finger

to

fioor

distance

_(cm)

Lumbar

extension

(degrees)

(SD)

41.6

(8.4)

1816926.7

(4.2)

38

17

11

5

5

4

7

18

_{21)

68

_{78}

38

{44}184

{156)11e

{39}15,8

(5,4}2e.4

(7,6)13,2

(4,3)

5.5

{2.0)

3e,4

{32,3)

3e,4

{28,5)

22.8

_(13.5)

12,1

(7.6)

42,5

_(8,4}

19f6827,2

(4,O}

35

ll

16

6

5

4

9

20

(23)

68

_{78)

42

(48)199

{135}102

(42)15,6

(7,3)18.9

(7.8)13,O

(4,8}

5.7

(2.2)

25,9

(25.9)

25,5

(22.8)

26.7

_(15.1)

10.6

(6.5)

Stattstical

Analysis

Ana}ysis

was

performed

by

intention-to-treat.

Between-group

comparisons at

baseline,

after

treatment

and at

3

and

12

months of

follow-up

were

performed

with chi-square

tests

for

categorical variables.

Independent

samples

T-tests

were

applied

in

continuous variables with a norrnal

distribution

and a

Mann-Whitney-U

Test

in

nen-parametric continuous variables.

Effect

sizes

(ES}

were computed

for

alloutcomes.

In

continuous variables with a normal

distribution

Cohen's

d

was computed

by

clividing

the

mean

difference

in

change

between

the

two

_groups

by

the

standard

deviation

of

the

change

in

the control

_group.

If

results were analyzed with

the

generai

Iinear

method, we

derived

the

ES

from

eta234).

Positive

values of

ES's

display

desirable

effects,

Effect

sizes of

.20

were considered small,

.50

were regarded as moder-ate, and

.80

were regarded as

large35).

Statistical

analysis was

performed

with

SPSS

Version

11,5.

Alpha

was set at

O,05,

Results

Between

January

lst

2000

and

May

lst

2003,

260

eligible

patients

were referred

to

the

rehabilitation center and

174

participated

in

the

study.

During

the

treatment

phase

one

patient

of

the

FT-group

dropped

out

because

he

was

diag-nosed with a necrosis of

the

head

of

the

femur

and

under-went surgery.

The

measurements after

treatment

were missed

in

two

patients

from

the

PT-group

due

to

a

reduc-tion

in

the

length

of stay oi

1

and

4

days

not noticed

by

the

research assistant.

The

number of

days

at work was obtained

in

99%

of

the

patients

at

three

month and

94

%

and

97

%

of

the

patients

in

the

FCT

and

PCT

group

respec-tively

at

12

month.

There

were ne significant

differences

of

the

most

important

pregnostic

and eutcome variables

between

the

groups

after randomization

_(Table

1).

Adherence

to

and

Satisfhction

with

the

Pretocog

The

length

of stay was comparable

in

both

_groups

with

22.2

days

(SD=3.7)

in

the

FT-group

and

22.3

days

(SD=3.8)

in

the

PT-group.

All

patients

attended at

least

90%

of

the

scheduled

treatments.

One

patient

in

the

FT-group

was not

treated

according to the

_pretocol

because

she

insisted

on

getting

hot

packs

and massage

for

_pain

relief,

Overall

sat-isfaction

with

treatment,

satisfacrien with advice received,

knowledge

about the complaints and the

_perceived

possibil-ities

to

influence

the

comp!aints were

the

same

in

the

two

groups

Tndicating

that

the

effort

to

keep

_patients

unaware of any expected

treatment

advantage was successful.

Outcome

measurement

NII-Electronic Library Service

332

-"fitze

rg34tsas8e

Table

2

Outcome

after

Treatment,

3

and

12

Months

(a

Mann-Whitney

U-Test,

b

between-within

Subjects

ANOVA)

Square

Test,C

Mixed

Function-centeredNPain-centeredNES

p-value

SeLf-ethcacy

{changei

PACT,

SD)

Lifting

capacity

{changei

kg,

SD]

fioor-waist

horizontal

waist-shoulders

Perceived

effeeti

_{mean,

_SD)

physical

capacity

general

well-being

overall

improvement

Pain

(change

NRS

O-10,

SD}

post

3

rno

Muscle

_performance

_(changei,

seconds,

SD)

Extensien

hlpltrunk

Flexion

trunk

Finger

to

floer

distance

(changei,

cm,

SD)

Lumbar

extension

(changei,

degrees,

SD}

Days

at work2

{mean,

SD)

Days

at work3

{mean,

SD)

5.9

2.3

1.7

1.3

4,l

4,O

4.4

-O.25

O,35

8.6

O.7-2.9-1.025,9118

(32.5)

(5.4)(5.9)(3.2)

(2.1)(2.1)(2.0)

(2.1)

(2.1)

(26,2)(21.6)(Z7)(6.3)(32.2)(134)

86

868686

868686

8686

868686868682

-7.4

_(24.4)

O.2

(3,9)-O.2

(6.0)n2

(3.7)

2.9

(1,n

3.1

(1,9)

3.6

(2.0)

O.55

(1,9)

O.89

(1,9)

2.5

(24.9)

-1.9

_(18.4)

O.O

(8,3)

O.4

_(7.0)15.8

(27,5)

74

(114)

85

858585

858585

8585

858585858784

O.55

_o.oo3

C

O.54

o,oo4

e

O.32

o.o4g

C

O.41

O,O06

[

O.71

O.OOO07

O.47

O,O05

O.40

O.O09

O.42

o,o23

C

O.28

o,og4

C

O.24

O.121

C

O.14

_O.3gs

C

O.44

o,ols

C

-O.20

_o.166

C

O.36

_o,o2g

a

o.3s

o,oll

a

iMeasurement after

treatment

2Measurement after

3

effect size

favoring

the

FT

was

found

for

the

primary

and most of the secondary outcomes.

After

3

months

there

were more

days

at work

in

the

FT

group

compared with

the

PT

group

25.9

vs

15.8

_(ES

=

O.36,

p

=

O,029)

and after

12

month

days

at work were

118

vs

74

_(ES

O,35,

_p=

O.Oll).

Regarding

the

secondary outcomes after

treatment,

the

FT-group

had

improved

significantly more

in

selfefficacy, all

three

tests

for

1ifting

capacity and

for

the

perceived

effect

The

mod-erate effect sizes

for

the

perceived

effect after rehabilitation

were not maintained

during

the

3-month

follow-up

peried.

Pain

intenslty

was significantly

lower

in

the

FT-group

after

treatment.

During

the

three-month

follow-up

peried,

pain

increased

in

both

groups

but

the

difference

in

favor

of

the

FT-group

remained.

No

difference

was

found

in

back

and

hip

extensor strength,

trunk

fiexor

strength and spinal

mobil-ity.

Discussion

This

is

the

first

RCT

in

Switzerland

evaluating

work-relat-6d

rehabilitation

in

_patients

with

LBP.

work

absence was

significantly reduced and more

_patients

had

returned

to

work after

three

months,

The

PT-group

did

not achieve the

goal

of

pain

reduction.

Pain

intensity

increased

in

this

group

while

it

decreased

in

the

FT-group.

The

pain

reduetion

in

the

FT-group

supports

the

hypotheses

that

fear

for

pain

may

be

mere

disabling

than

pain

itself36).

Compared

with other studies,

the

results of

this

study are remarkable

because

two

experimental

treatments

were

com-months, 3Measurement after

12

months.

pared

resulting

in

a reLatively small

treatment

contrast,

In

a recent review, only one out of nine comparisens

between

two

experimental

treatments

showed a significant effect24L

The

ES

for

work absence

in

this

study

is

similar

to

the

ES

in

five

studies comparing

intensive

treatment

with usual

care37'4i).

usual

care essentially consisted of

treatment

by

a

general

physician

giving

advice and

prescribing

medications,

Excluding

patients

who will not

benefit

from

treatment

is

essential

to

increase

statistical

pewer

and efficiency of an

RCT.

The

positive

results and

the

high

follow-up

rate

in

this

study were

in

part

the

result of excluding

patients

with

pos-itive

predictive

tests

for

nen-return

to

work,

identified

in

a

prevlous

study25).

In

an attempt

to

evaluate whether

exclu-sion was

justified,

we evaluated work absence

by

sending

questionnaires

and reminders

to

the

excluded

patients,

whe

had

also attended

three

weeks of rehabilitation.

The

nen-response rate

in

this

group was

30%

and only one of

the

patients

had

returned to work, confirming

the

value of

the

predictive

tests.

Although

the

number of work

days

increased

significant-iy

in

the

FT-greup,

the

problem

of

LBP-related

work absence and

disability

is

obviously not solved.

Considering

the remaining amount of work absence

in

the

FT-group,

the

effect of

the

FT

treatment

can

be

considered

disappointing

and

too

smalL

The

investigated

greup,

however,

is

charac-terizecl

by

Iong-standing

sick

leave,

heavy

work and

low

edu-cation resulting

in

a

limited

possibiLlty

to reduce work

demands.

Return

to

work

is

additionally

limited

because

less

Function-

Versus

Pain-Centred

Treatment

of

demanding

jobs

are

hardly

available on

the

employment

mar-ket,

Only

two

patients

found

a new

job.

Knowledge

of

the

Swiss

national

languages

was

limited

in

more

than

50%

of

the

patients

participating

in

our work

rehabilitation

program

Treatment

was

developed

to

be

applicable

te

these

patients.

The

key

element of

the

FT

treatment was activity effered as

isokinetlc

and

werk-relat-ed training, walking and sports

therapy,

This

treatment

did

not need

proficient

verbal eommunication and could

be

applied

to

this

greup

of

patients,

increasing

the

external validity of

the

study.

The

external validity of

this

study

is

further

supported

by

the

patient

population,

representative

for

patients

in

SwitzerEand

with

LBP,

who are at risk of

permanentiy

los-ing

working capacity,

becoming

unemployed or

becoming

dependent

on a

disability

allowance.

The

majority of

the

patients

were

heavy

workers

born

in

other eountries,

poor-ly

educated and

having

insufficient

personal

resources,

par-ticularly

insufficient

knowledge

of

the

Swiss

national

lan-guages,

to

participate

successfully

in

vocational measures.

other

studies 3S'40' 42'43) only

included

patients with

proficient

knowledge

of the national

tanguage,

giving

them

a

better

perspeetive

to

participate

in

vocational measures and

to

find

lighter

work.

Assessments

in

this

study

had

to

be

either

available

in

allrequired

languages

or

be

independent

of

lan-guage,

The

PACT

selfefficacy assessment

does

not require

proficient

knowledge

of

language

because

it

uses

pictures

ef

physical

activlties.

Conclusion

Function-centered

rehabilitation

decreases

work-related

disability.

The

effect sizes were small

to

moderate.

The

num-ber

of

days

at work

during

the

three

months of

follow-up

was

10

days

higher

in

the

FT-group

and

44

days

higher

after

12

months.

Selfefficacy,

lifting

capacity and

pain

inten-sity

impreved

significantly

in

the

FT-group.

The

number of

days

at work

did

not

depend

on sex, age, workload and

nationality.

Function-celltered

treatment

should

be

used

instead

of

the

still widespread

pain-centered

treatments,

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