Efficacy of multidisciplinary treatment for patients with chronic low back pain: a prospective clinical study in 395 patients.

BACKGROUND: The effectiveness of multidisciplinary treatment programs varies throughout the literature, and it remains controversial how therapy outcome is affected by patients' individual parameters and which treatment settings work best. OBJECTIVES: We set out to examine the impact of patient variables on the effectiveness of a 3-week multidisciplinary treatment program in patients with chronic low back pain. By presenting effect sizes, we aimed to enable the comparison of our findings with other studies across disciplines. METHODS: Data on 395 patients were prospectively collected at study entry, at the end of the program (T1) and after 6 months' follow-up (T2). Relevant therapy outcomes were analyzed by presenting effect sizes with Cohen's d. Group comparisons were performed for sociodemographic and clinical features to determine the impact on therapy outcome. RESULTS: Medium effect sizes (d = -0.6 to -0.7) were shown for visual analog scale (VAS) after treatment and at T2, indicating clinically relevant pain relief. Significant changes in pain-related disability were observed immediately at T1 with a strong treatment effect (d = 0.8). Functional capacity was improved with low to medium effect sizes (0.4-0.5). Quality-of-life subscales (36-item Short Form Health Survey) improved significantly at T1 for physical function, vitality, and mental health (d = 0.5-0.8). Center for Epidemiological Studies - Depression Scale scores improved significantly with strong effect sizes of d = 0.7. Sociodemographic parameters displayed a significant impact on effect sizes for visual analog scale at T2, with females (d = -0.9), age group 30 to 39 years (d = -1), and patients with low physical job exposure (d = -0.9) benefiting most. An increase in number of pain locations (-0.7) and severity of accompanying pain (-0.7) in other body areas significantly impaired therapy outcome and effect sizes of VAS. CONCLUSIONS: Thus, multidisciplinary treatment ameliorates pain, functional restoration, and quality of life with medium to high effect sizes even for patients with a long history of chronic back pain. Effect sizes are higher than for monodisciplinary treatments and treatment effects remained stable at 6-month follow-up in a longitudinal uncontrolled study design. Thus, we believe that multidisciplinary treatment is vital for the treatment of patients with chronic low back pain. The impact of sociodemographic and pain-related parameters needs to be taken into account when including patients in an appropriate treatment program. We emphasize the presentation of effect sizes as a vital treatment evaluation to enable cross-sectional comparison of therapy outcomes.

The impact of pathological fractures on therapy outcome in patients with primary malignant bone tumours.

The primary objective of this study was to investigate the implications of pathological fractures on therapy outcome in patients with primary malignant bone tumours and to determine whether limb salvage can be safely performed. A retrospective analysis of 447 patients with primary malignant bone tumours, treated between 1985 and 2005, was performed. Multivariate Cox regression analysis was used to investigate the influence of pathological fractures and further independent variables on survival rate. In 52 of the 447 patients, the primary malignant bone tumour was complicated by a pathological fracture. These fractures were more common in malignant fibrous histiocytoma (MFH) of the bone and in the tumour stages IIa/b and III. Ablative surgery was performed in ten patients and limb salvage surgery in 42 patients. The mortality risk for patients with pathological fractures was significantly increased by a factor of 1.82 (p = 0.015), and overall duration of survival was significantly lower in the fracture group, with a median of 6.2 years (p < 0.00001). In univariate and multivariate analysis, fracture, higher tumour stages and resection margins remained a significant predictor of worse survival. Overall survival, rate of local recurrence and distant metastases were not affected by the type of surgical treatment selected; there was no difference between the patients who underwent limb salvage and those who underwent an amputation. Pathological fracture in patients with primary malignant bone tumours is a predictor of worse survival and significantly increases mortality risk. Reconstructive surgery did not influence the survival rate, showing that limb salvage therapy is safe when adequate resection margins are achieved.

The value of physical performance tests for predicting therapy outcome in patients with subacute low back pain: a prospective cohort study.

Considering the enormous costs of intensive multidisciplinary treatment, predictive tests for therapy outcome are needed to evaluate patients' performance potential and increase cost effectiveness. Somatic parameters are commonly used to evaluate health status and serve as an additional means of forecasting the prognosis, yet little is known of their validity. In this study, we investigated the prognostic value of somatic parameters regarding the outcome of multidisciplinary treatment in patients with subacute low back pain. The study was designed as a prospective cohort study of 162 patients. Somatic parameters were assessed with three physical performance tests (Villiger test, Oesch test, Biering-Sørensen test) before treatment (T0), after 3 weeks' inpatient therapy (T1) and at 6-month follow-up (T2). Psychometric characteristics of subjective pain perception (VAS), a pain disability index (PDI) and a physical capability index (FFbH-R) were recorded. Correlation coefficients between the physical performance test scores and psychometric characteristics were calculated. To predict therapy outcome, discriminant analyses were performed. A control group (n = 30) was evaluated at similar time points without receiving any therapy. Our results demonstrate good discrimination between patients and controls by means of the investigated performance tests and exhibit a significant negative correlation with the psychometric data. Lower outcome values at study entry correlated with higher pain intensity and disability after multidisciplinary treatment. However, the statistical magnitude of correlation was relatively low and further discriminant analysis did not reveal any predictive value. Consequently the physical performance tests do not have a prognostic value regarding therapy outcome.

Age as a predicting factor in the therapy outcome of multidisciplinary treatment of patients with chronic low back pain--a prospective longitudinal clinical study in 405 patients.

This prospective longitudinal clinical study evaluates the prognostic value of age in the therapy outcome of patients with chronic low back pain treated with a multidisciplinary therapy. Four hundred five patients with chronic low back pain for 3 months or longer and a corresponding sick leave for longer than 6 weeks underwent a 3-week standardized multidisciplinary therapy. Patients were assigned into three groups of age with comparable baseline values at T0. At the 6-month follow-up (T1) five different therapy outcomes were analysed and compared in the three groups: back-to-work status, generic health status (SF36), pain intensity, functional capacity, and satisfaction with the therapy. All three treatment groups improved significantly in all outcome criteria between T0 and T1 except of functional capacity, which did not improve in the older patients. In the total group, the back-to-work rate was 61.7%. At the final follow-up, there were significantly better results in terms of functional capacity and pain level in younger patients, whereas back-to-work rate and satisfaction with therapy did not show a significant difference between the groups analysed. According to the results of this study, older patients with chronic low back pain also derive significant benefit from a multidisciplinary treatment strategy, although in some outcome criteria results were inferior to those obtained in younger patients.

The impact of pain spread on the outcome of multidisciplinary therapy in patients with chronic musculoskeletal pain - a prospective clinical study in 389 patients.

BACKGROUND: Musculoskeletal pain represents a continuous process ranging from single-site to multiple-site pain, with an increase in pain sites accompanied by an increasing risk of chronification and the development of further comorbidities. Within this context, the impact of pain spread on therapy outcome is still unknown. AIMS: This prospective clinical study aimed to evaluate whether and to what extent patients with pain at multiple sites would also benefit from multidisciplinary therapy or whether therapy success is limited by pain spread. METHODS: Patients' characteristics were assessed, including socio-demographic variables, occupational and workplace characteristics, pain intensity and dimensions of pain, psychological aspects and functional back capacity, as well as the generic health status. Data were prospectively collected at day 1 (baseline) and at 6-month follow-up from a sample of 389 patients undergoing multidisciplinary treatment. Patients were distributed into three groups based on the number of pain sites (single-site, dual-site and multiple-site) and the outcome parameters were compared. RESULTS: All three groups improved significantly from baseline to the 6-month follow-up. Compared to patients with multiple-site pain, patients with single-site and dual-site pain displayed significantly better outcome on almost all measures. Only the subcategory mental health of the SF-36 did not show any statistically significant differences among the three groups. CONCLUSIONS: Our results display that patients with two or more pain sites also improve significantly in the outcome measures. Therefore, treatment should be offered independent of the extent of pain spread. However, therapy is significantly less successful in patients with pain at multiple sites.

The influence of the grade of chronicity on the outcome of multidisciplinary therapy for chronic low back pain.

STUDY DESIGN: Prospective longitudinal clinical study. OBJECTIVE: The objective of the study was to analyze the outcome of different stages of chronicity in patients with chronic low back pain treated with a multidisciplinary therapy. SUMMARY OF BACKGROUND DATA: Results of studies comparing different grades of chronicity in therapy for chronic low back pain have not been published so far. METHODS: A total of 387 patients with chronic low back pain for 3 months or longer and a corresponding sick leave for longer than 6 weeks underwent a 3-week standardized multidisciplinary therapy. At baseline (T0), patients were assigned into 3 groups of chronicity grades according to the classification of von Korff et al (Group A, Grades I and II; Group B, Grade III; Group C, Grade IV) and were prospectively followed. At the the 6-month follow-up (T1), 5 different therapy outcomes were analyzed and compared in the 3 groups: back-to-work status, generic health status (SF-36), pain intensity (visual analogue scale), functional capacity (Hannover back capacity score), and satisfaction with the therapy. RESULTS: At T0, patients in Group C had a higher pain level, a longer history of pain, and more general and more psychosomatic comorbidities than patients with lower levels of chronicity. All 3 treatment groups improved significantly in all outcome criteria between T0 and T1. In the total group, the back-to-work rate was 67.4%. At the final follow-up, there were significantly better results in terms of functional capacity and pain level in patients with lower grades of chronicity but mostly due also to worse initial baseline values. Back-to-work rate, satisfaction with therapy, and the Mental Component Summary of the SF-36 did not show a significant difference at T1 between the groups analyzed. CONCLUSION: According to the results of this study, patients with chronic low back pain also derive significant benefit from a multidisciplinary treatment strategy in higher stages of chronicity. Therefore, therapy should not be limited to the patients in lower stages of chronicity.

Prognostic significance of drug-regulated genes in high-grade osteosarcoma.

About 25-45% of patients with high-grade osteosarcoma poorly respond to chemotherapy with an increased risk of relapse and the development of metastasis. Therefore, the aim of this study was the evaluation of the prognostic value of eight previously identified drug-regulated candidate genes on osteosarcoma therapy outcome. Gene expression of 8 candidate genes was analyzed in 35 formalin-fixed, paraffin-embedded, laser-microdissected osteosarcoma biopsies. The prognostic value of these genes was evaluated by the correlation of gene expression with therapy outcome, overall survival and event-free survival in univariate and multivariate analysis. Upon univariate analysis, the expression of MALAT-1, IMPDH2, FTL and RHOA significantly correlated with response to chemotherapy. Expression of all four genes was increased in the poor responder group. Upon multivariate analysis, IMPDH2 maintained its independent prognostic value (P=0.025). Concerning the overall survival of the patients, we observed a significant association with the expression of FTL, PHB, ATAD2, ACTN1 and RRM2 as well as lactate dehydrogenase serum levels. In the subgroups of patients with high expression of these genes and those with elevated lactate dehydrogenase levels, the mean overall survival was decreased 1.7-, 1.9-, 2.2-, 2.4-, 1.5- and 4.5-fold, respectively. Except RRM2, all genes and lactate dehydrogenase serum levels remained significant in the multivariate analysis. In addition, the event-free survival was significantly decreased in the subgroups of patients with high FTL, ATAD2 and IMPDH2 expression (1.8-, 6.3- and 2.4-fold, respectively). These data demonstrate that among the identified genes are valuable markers for the prediction of osteosarcoma therapy outcome. Especially IMPDH2 and FTL are promising candidates for the stratification of osteosarcoma patients into low- and high-risk groups. Owing to their involvement in drug action these genes may further be potential targets for the modulation of drug sensitivity.