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decisions, advice given after therapy, the healthcare
and insurance system, as well as educational treatment,
and may not be sufficiently taken into account by the
therapists. Social factors were shown to influence
functional limitation and disability in low back pain,
with social disadvantage being one of the important
factors (16).
In Switzerland, the population with foreign citi-
zenship has grown continuously since 1983 and had
reached 24.6% of the total population by 2015. This is
one of the highest percentages of foreign residents in
Europe. In Switzerland, 84.7% of the foreign perma-
nent resident population are of European origin, and
the largest group of foreigners are Italian at 15.2%
(17). Reactions to health-illness process are different
in each culture and are influenced by the patient and
by interpretations and attitudes that lead to a certain
way of living with the disorder (18). More intercul-
tural competence, awareness and culturally sensitive
attitudes are required in medical treatment in order to
meet the needs of these different groups better, e.g. by
standardized IPMPs held in specific languages.
No studies have investigated the differences in chan-
ges as a result of the same IPMP with the same therapy
components held in 2 different languages, administered
by the same therapists. The objective of this study
was to describe and to examine state (at baseline) and
short-term (at discharge) as well as mid-term (at 3-, 6-,
and 12-month follow-up) changes in biopsychosocial
health and quality of life in Italian-speaking patients
(ISP) with fibromyalgia, generalized widespread pain
and chronic non-specific back pain before and after
a standardized 4-week IPMP in the Italian language.
Furthermore, the study aimed to compare the results of
the ISP with the results of German-speaking patients
(GSP) at follow-ups.
METHODS
Patients
Patients included in this study were recruited at the pain cen-
tre of the rehabilitation clinic “RehaClinic” in Bad Zurzach,
Switzerland. All patients with chronic non-specific back pain,
fibromyalgia according to the American College of Rheuma-
tology (ACR) definition (19), or generalized widespread pain
(pain in all 4 body quadrants not fulfilling the ACR criteria of
1990 (19)) who attended the “Zurzach Interdisciplinary Pain
Program” (ZISP) were invited to participate. Further inclusion
criteria were age ≥ 18 years and chronic pain for ≥ 3 months. Ex-
clusion criteria were severe somatic or mental illness/condition
that prevented participation in the IPMP, insufficient language
skills (reading and writing) to complete the assessment tool,
and refusal to participate in the study or the IPMP.
Prior to inclusion in the IPMP and based on the admission
report, potential participants were contacted by telephone by
the programme leader (RB) or his assistant (both of whom are
www.medicaljournals.se/jrm
bilingual in German and Italian) to complete inclusion and ex-
clusion criteria and to assess oral language skills (listening and
speaking). Allocation to the groups was based on oral language
skills and not on migration background. For example, all patients
participating in the German-speaking programme had excellent
oral German language skills, which were an inclusion criteria.
Patients with insufficient oral German or Italian language skills
(exclusion criteria) were admitted to a different, individual
IPMP in our clinic.
Each group underwent a specific Italian- or German-speaking
IPMP. This means that all information and instructions were
given either in German or Italian. Both language-specific pro-
grammes consisted of the same therapy components, the same
therapeutic content, and the same number of therapies. All
therapies in the programme were provided by the same therapists
for the German, as well as for the Italian, group.
Written informed consent was obtained from all participants.
The study protocol was approved by the Local Ethics Com-
mission (Health Department in Aarau, Switzerland, EK AG
2008/026).
Intervention
The ZISP is a 4-week, standardized, comprehensive, inpatient
IPMP in groups. The IPMP focused on chronic musculoskeletal
pain disorders and consisted of active physiotherapy, and ae-
robic endurance training, Qigong/tai chi exercises, individual
psychotherapy including cognitive behavioural therapy, par-
ticipation in a pain coping group, relaxation therapy, humour
therapy, horticultural therapy (since April 2006), information
and education about the pathophysiology of pain mechanisms
and management of chronic disabling pain, nursing care, and
regular medical consultations, including drug therapy. Details
of the IPMP are provided elsewhere (6, 7).
Data sampling
In this prospective cohort study, 2 different samples are descri-
bed and analysed. Sample 1 was collected between 2001 and
2005 with follow-up measurements at 3 and 6 months (Fig. 1),
sample 2 between 2006 and 2014 with follow-up measurements
at 12 months. In 2006, the follow-up measurements at 3 and 6
months were replaced by one follow-up measurement at 1 year
after entry to the programme. This decision was based on the
findings for the GSP analysed in sample 1. In this study, only
mid-term results were calculated (3 and 6 month follow-up)
(6). In the following, long-term results came into our focus of
interest, especially because these could not otherwise be found
in the literature at that time. A further reason for the restart with
the “revised” sample strategy (sample 2) of the IPMP was that
a new, improved version (version 2) of the Medical Outcomes
Study Short Form 36 Health Survey (SF-36) was available and
included in the measurements (20).
For these reasons, the size of sample 1 was limited. The ana-
lysis based on sample 1 revealed relatively high effect sizes for
many health scales (6). Thus, data sampling for sample 2 was
considered sufficient after having reached n ≥ 60 for both the
German- and the Italian-speaking group. Doubling the sample
size up to n = 120 for each group would narrow the width of
the 95% confidence interval of the effect sizes by 0.02. This
gain was considered to be too small in face of the burden of
doubling the sampling effort.
The difference in number of included patients in sample 1 and
the difference in duration of inclusion of the patients in sample
2 were due to the naturalistic study design and the maximal