Geschlechtsspezifische Unterschiede und weitere psychosoziale Faktoren in der stationären orthopädischen Rehabilitation von chronisch unspezifischen Rückenschmerzen: Psychologischer Behandlungsbedarf und langfristige Effekte einer störungsspezifischen kognitiv-behavioralen Intervention

Abstract

Background: Psychosocial factors, in particular co-existing depressive symptoms, are highly associated with chronic low back pain (CLBP). As females with CLBP show higher psychological and pain-related impairments than males, it may be assumed that women in orthopaedic inpatient rehabilitation of CLBP are more prone to develop chronic pain. Overall, the development of individualised multimodal intervention programmes is indicated. Thereby, patients at high-risk to develop chronic pain need to be identified and subsequently allocated to specific psychological interventions. Purpose of the presented work was to determine gender-specific differences and further psychosocial factors in inpatient orthopaedic rehabilitation of CLBP. Moreover, long-term effects of a specific psychological intervention for patients with CLBP and co-existing depressive symptoms were investigated in comparison to the solely standard rehabilitation. Objectives and Results: First, the criterion validity of the Mainz Pain Staging System (MPSS; Gerbershagen, 1996) was examined among patients with CLBP in orthopaedic inpatient rehabilitation, considering the four axes of the MPSS separately. For each axis, psychosocial variables were analysed depending on the stage of axis (I, II, III). Results showed that an increasing stage of axis was associated with more severe impairments in pain-related and psychological variables for all axes (manuscript I). Furthermore, in realising a one-factorial design, psychosocial variables were investigated depending on gender among patients with CLBP in orthopaedic inpatient rehabilitation. Women showed significantly more severe impairments in psychological variables and functional capacity immediately after rehabilitation. Moreover, the development of chronic pain was more advanced in females than males (manuscript II). Finally, by conducting a three-factorial design, short-, mid-, and long-term effects of a cognitive-behavioural training for the management of depressive symptoms were examined depending on treatment condition and gender during a period of two years. Patients with none or mild depressive symptoms were treated with the standard rehabilitation (CG) and patients with moderate or severe depressive symptoms were either treated with the multidisciplinary standard rehabilitation (CGdepr) or the standard rehabilitation plus cognitive-behavioural management of depressive symptoms (IGdepr). All patients showed beneficial short-term effects in pain-related and psychological variables independent from the experimental condition. This favourable effect receded during follow-up in pain-related measures. In psychological outcome measures, patients in the IGdepr showed stable long-term effects up to the 24-month follow-up while patients in the CGdepr did not persistently improve (manuscript III and IV). Conclusion: Findings suggest that subgroups of patients at high-risk to develop chronic pain need to be identified at an early stage. The MPSS has proven to be a valid measure for the assessment of the stage of chronic pain in patients with CLBP in orthopaedic inpatient rehabilitation. However, in order to identify patients specific needs for psychological interventions, supplementary psychological diagnostics are needed. Especially, the high psychological needs among women with CLBP should be taken into account in orthopaedic inpatient rehabilitation. Further results showing severe psychological impairments in patients with enhanced chronic pain strongly encourage the implementation of specific psychological interventions among patients at high-risk for a further development of chronic pain. The newly developed training for the management of depressive symptoms has proven to be an effective psychological treatment module for patients with CLBP and co-existing depressive symptoms. The supplemental cognitive-behavioural training augmented long-term psychological rehabilitation success in this highly strained subgroup and, thereby, decelerated further development of chronic pain.