Journal of Rehabilitation Medicine 51-1CompleteIssue | Page 70

67
Effects of multimodal back exercise
Table IX. Percent changes in Graded Chronic Pain Status grade
shares
GCPS
GCPS
GCPS
GCPS
GCPS
0,
1,
2,
3,
4,
%
%
%
%
%
Pre
treatment 1 st year post
treatment 2 nd year post
treatment
BE ST BE ST BE
ST
0.0
31.3
30.9
24.3
13.5 0.0
35.6
28.9
17.4
18.2 1.7
67.0
15.1
10.0
6.2 3.6
39.5
19.9
21.4
15.6 2.9
68.1
12.4
10.2
6.4
3.5
46.1
23.8
13.7
12.9
BE: back exercise; ST: standard treatment
DISCUSSION
To our knowledge, this study is the first to investigate
the therapeutic and economic effects of a multimodal
back exercise programme in relationship to back pain
severity (measured with the GCPS). This information is
useful to patients with back pain and to health insurers.
A key finding of this study is that the therapeutic
effect is more pronounced the higher the level of
back pain (GCPS) before the start of the exercise pro-
gramme. Hence, the results point in the same direction
as current research: physical exercise achieves low to
moderate therapeutic effects for chronic back pain.
These effects could not be demonstrated for subacute
and acute back pain (10). However, the chronic, suba-
cute, and acute classification is made over the course of
the back pain, while the GCPS ranks the back problems
in a more complex fashion, over the course of the back
pain plus the pain intensity and pain-induced functional
impairment in daily life, leisure and work (11). Thus,
the results of the present study bring the connection
between the severity of the problem and the effecti-
veness of the exercise programme into sharper focus.
A novel finding is that the economic impact also
becomes more pronounced the more severe the back
pain experienced before the start of the exercise pro-
gramme. As Lühmann et al. (25) surmised, the largest
therapeutic and economic effects arise due to the high
initial probability in the high-risk groups. The direct
medical costs, and therefore also the potential for
economic impact, at GCPS grade 4 (severe functional
impairment) were more than double those at GCPS
grade 1 (Table V and Fig. 3). Indeed, for grade 4, the
multimodal back exercise represented a dominant stra-
tegy, considering that therapeutic effects were realized
in tandem with cost savings. For GCPS grade 1, by
contrast, the MWTP of 19,300 EUR seems too high.
This study helps to clarify the inconsistency in the
literature about the cost-effectiveness of back training
programmes (26, 27), since previous studies fell short
in determining the effects differentiated by the degree
of back pain. Furthermore, as shown in the present
study, the economic impacts occur with a delay, while
the therapeutic exercise effects appeared during the
year of the intervention, the cost-effects only impact
the second year following the start of the intervention
(Fig. 2). Consequently, studies with shorter follow-ups
are not set up to demonstrate the cost-effects.
The multimodal exercise concept rested on the basis
of discussed mechanisms of action, since the state of
the research did not reflect the extent to which the
positive effects of back training depend on the type,
intensity, and volume of exercise (25, 10). Adaptive
muscles and improved circulation in the muscle/joint
structures are adduced as possible causes for the ef-
ficacy of exercise for back pain (28). These adaptive
reactions depend on the frequency of exercising, the
exercise duration, and the loading. This speaks for a
dose-effect relationship, such as we also encounter, for
example, with cardio exercises (29, 30). The training
volume, and thus the dosing of the multimodal exercise
programme, therefore was conceived as correspon-
dingly high, with a half year of exercising (36 training
Table X. Changes in direct medical costs (EUR) and Graded Chronic Pain Status within in two years (post – pre)
Changes in direct medical costs
GCPS
GCPS
GCPS
GCPS
1
2
3
4
Changes in GCPS values
BE ST Difference BE ST Mean (SD) Mean (SD) absolute % 95% CI p Mean (SD) Mean (SD) absolute % 95% CI
897
617
971
367 491
517
1,011
4,909 406
100
–40
–4,543 [–367; 1,179]
[–801; 1,001]
[–1,787; 1,707]
[–7,262; –1,823] 0.303
0.827
0.964
0.001 0.1 (0.6)
–0.6 (0.7)
–1.3 (1.0)
–1.7 (1.3) 0.3 (0.9)
–0.3 (0.7)
–0.2 (0.9)
–0.7 (1.1) –0.2
–0.3
–1.0
–1.0 [–0.4
[–0.5
[–1.4
[–1.6
(4,339)
(4,750)
(7,666)
(7,215)
(5,246)
(5,458)
(6,909)
(18,189)
83
19
–4
–93
Difference
–64
123
442
158
;
;
;
;
p
0.1]
0.006
–0.1] 0.001
–0.7] < 0.001
–0.5] < 0.001
BE: back exercise; ST: standard treatment; SD: standard deviation; CI: confidence interval.
Table XI. Net monetary benefit (NMB) depending on differing maximum willingness to pay (MWTP) and Graded Chronic Pain Status
λ = 0 EUR
GCPS
GCPS
GCPS
GCPS
1
2
3
4
λ = 4,370 EUR
λ = 7,500 EUR
λ = 19,300 EUR
Mean 95% CI p Mean 95% CI p Mean 95% CI p Mean 95% CI p
–406
–100
40
4,543 [–1,179; 367]
[–1,001; 801]
[–1707; 1,787]
[1,823; 7,262] 0.303
0.827
0.964
0.001 –16
842
3,403
  [–1254; 1,222]
[–552; 2,235]
[13; 6,792]
  0.980
0.236
0.049
  627
1,834 [–912; 2,167]
[10; 3,659] 0.424
0.049

  3,052 [10; 6,093] 0.049
J Rehabil Med 50, 2018