Zusammenfassung
Problem
Untersuchungen von Patienten mit chronischen Rückenschmerzen zeigen, daß es im Laufe des Chronifizierungsprozesses zu erheblichen körperlichen Funktionsdefiziten einerseits sowie Angst-, Schon- und Vermeidungsverhalten (wegen der Schmerzen) andererseits kommt. Bei der Therapie dieser Patienten haben sich deshalb in den USA und skandinavischen Ländern aktive Behandlungskonzepte durchgesetzt, die beides berücksichtigen und in dieser Form in Deutschland bisher noch nicht durchgeführt worden sind.
Methode
90 Patienten mit chronischen Rückenschmerzen und mehrmonatiger aktueller oder unmittelbar zurückliegender Arbeitsunfähigkeit wurden hinsichtlich ihrer körperlichen Funktionsdefizite zu Beginn, nach Abschluß der Behandlung sowie 6 und 12 Monate später untersucht; Das Behandlungsprogramm bestand aus einer 3-wöchigen Vorbereitung (Unterricht, Dehnung, kalisthenische Übungen) und einer 5-wöchigen Hauptphase, in der Aerobic, funktionelles Krafttraining, Ausdauer- sowie Haltungs-und Bewegungstraining sowie kognitive Verhaltenstherapie durchgeführt wurde. Evaluiert wurden Beweglichkeit von Rumpf, LWS und Becken mittels Inklinometer, Länge der Ischiocruralen Muskulatur, Kraft und Ausdauer der Rumpfmuskulatur mittels standardisierter Übungen sowie isokinetischer Testung (LIDOTM Back), Hebevermögen (LIDOTM Lift) sowie z. T. Herz-Kreislaufausdauer mittels Fahrradergometer. Die Validität der Funktionsdefizite wurde anhand der Untersuchung von 109 gesunden Personen ohne Rückenschmerzen, die Reliabilität der Teste durch Wiederholung der Evaluation durch verschiedene Untersucher durchgeführt.
Ergebnisse
Patienten mit chronischen Rückenschmerzen hatten gegenüber einer Normstichprobe erhebliche körperliche Funktionsdefizite. Nur die Rumpfbeugemuskulatur war nicht signifikant abgeschwächt. Nach Abschluß der Behandlung waren alle funktionellen Defizite signifikant verbessert und in vielen Fällen mit der Normstich-probe vergleichbar. Im Laufe der Zeit verschlechterten sich die Werte wieder und erreichten teilweise die Ausgangswerte.
Schlußfolgerung
Patienten mit chronifizierten Rückenschmerzen haben erhebliche körperliche Defizite, können aber durch ein intensives körperliches Training erfolgreich behandelt werden. Da sich die Funktionsdefizite aber über die Zeit wieder einstellen, ist eine Kontrolle der Befunde, bzw. der Heimübungs-programme auch nach Abschluß der Therapie notwendig.
Abstract
Problem
There is a great need to expand current knowledge of the various functional capacity measurements used in the rehabilitation of chronic low back pain (CLBP) patients. The literature on these patients reports that mobility, endurance, trunk strength and lifting capacity decrease during the process of chronicity. Chronically disabled patients appear to have lower functional capacity than asymptomatic persons.
Methods
Our study group consisted of 90 disabled CLBP patients (44 female, 46 male; average age 42 years) who underwent a multidisciplinary 8-week daily treatment program of functional restoration with behavioral support (instruction, endurance training, strength exercises, behavioral and treatment to facilitate return to work therapy). Initially these patients where compared with 107 asymptomatic persons (44 female, 63 male, average age 41 years). The patients were investigated before and after treatment, and at intervals of 6 and 12 months. The reliability of the functional measurements was evaluated by inter-rater comparison. Physical assessment included a medical examination (mainly diagnosis of radicular or nonradicular pain), changes in the lumbar spine revealed by X-ray studies according to Herron and Turner [50], rating of physical impairment according to Waddell [117], flexibility, length of hamstrings muscles (SLR), test of power and endurance of trunk movement by standardized exercises according to the Swiss group of Spring [102] and isokinetic measurements (LIDO Back), tests of lifting capacity (LIDO Lift), and (in part) of general endurance on a cycle ergometer (CASE 15 Marquette).
Results
Physical findings showed that mobility was reduced substantially in patients suffering from back pain due to reduced SLR (shortened hamstrings) and decreased spinal mobility.
Patients also demonstrated significant reductions in their ability to perform lifting tasks in comparison to healthy individuals. The results of trunk flexion showed no significant differences between patients and the control group, whereas the ability to perform trunk extension was much better in the control group. In principle we found the same results with isokinetic measurements as in the exercises without machines. Cardiovascular endurance was also much better in the control group than it was in the back pain patients. At the end of the treatment program all physical deficits were improved significantly. In many cases performance was comparable with that of the control group. With time, however, training effects gradually decreased. The success of treatment (return to work, absence from work, pain reduction, use of medical care) was independent of the functional status of the patients before and after treatment.
Conclusion
Study results showed that physical capacity in disabled patients with low back pain is substantially reduced in comparison to persons who do not suffer from back pain. The only exception was in trunk flexor strength and endurance, in which measurements did not differ between the patients and the control group. However, even CLBP- patients with long-term pain and sevee physical illness can successfully improve their physical condition by participating in an active treatment program. Back extensor muscle training has to be included in physical therapy. Because of loss of condition during the time after treatment, regular monitoring of papients and their home training programs is necessary. Overall, treatment of CLBP has to include physical trainingand psychosocial treatment to achieve satisfactory results.
Literatur
Alaranta H, Tallroth K, Soukka A, Heliovaara M (1993) Fat content of lumbar extensor muscles and low back disability: a radiographic and clinical comparison. J Spinal Disord 6: 137
Alaranta H, Rytökoski U, Rissanen A, Talo S, Rönnemaa T, Puukaa P, Karppi SL, Videman T, Kallio V, Slätis P (1994) Intensive physical and psychosocial training program for patients with low back pain. Spine 19: 1339
Alpert J, Matheson L, Beam W, Mooney V (1991) The reliability and validity of two new tests of maximum lifting capacity. J Occup Rehabil 1: 13
Andersson GB, Svensson HO, Oden A (1983) The intensity of work recovery in low-back pain. Spine 8: 880
Bandura A (1982) Self-efficacy mechanism in human agency. Am Psychol 37: 122
Battié MC, Bigos SJ, Fisher LF, Hansson TH, Jones ME, Wortley MD (1989) Isometric lifting strength as a predictor of industrial back pain reports. Spine 14: 851
Bigos SJ, Battié MC, Spengler DM, Fisher LD, Fordyce WE, Hansson T, Nachemson AL, Wortley MD (1991) A prospective study of work perceptions and psychosocial factors affecting the report of back injury. Spine 16: 1
Bigos SJ, Battié MC, Spengler DM, Fisher LD, Fordyce WE, Hansson T, Nachemson AL, Zeh J (1992) A longitudinal prospective study of industrial back injury reporting. Clin Orthop 279: 21
Boden S, Davis D, Dina T (1990) Abnormal magnetic resonance scans of the lumbar spine in asymptomatic subjects. J Bone Joints Surg 72A:403
Bogduk N (1983) The innervation of the lumbar spine. Spine 8: 286
Boston JR, Rudy TE, Lieber SJ Stacey BR (1995) Measuring treatment effects on repetitive lifting for patients with chronic low back pain: speed, style and coordination. J Spin Dis 8: 342
Brennan GP, Ruhling RO, Hood RS, Shultz B, Johnson S, Andrews B (1987) Physical characteristics of patients with herniated intervertebral lumbar discs. Spine 12: 699
Burke SA, Harms-Constas CK, Aden PS (1994) Return to work/work retention outcome of a functional restoration program. Spine 19: 1880
Burton AK, Tillotson KM, Troup JDG (1989) Variation in lumbar sagittal mobility with low back trouble. Spine 14: 584
Cady LD, Bischoff D, O’Connel E (1979) Strength and fitness and subsequent back injuires in firefighters. J Occup Med 21: 269
Cairns D, Mooney V, Crane P (1984) Spinal pain rehabilitation: inpatient and outpatient treatment results and development of predictors for outcome. Spine 9: 91
Carpenter DM, Graves JE, Pollock ML, Leggett SH, Foster D, Holmes B, Fulton MN (1991) Effect of 12 and 20 weeks of resistance training on lumbar extension torque production. Phys Ther 71: 580
Caruso LA, Chan DE, Chan A (1987) The management of work-related back pain. Am J Occup Ther 41: 112
Cassisi JE, Sypert GW, Salamon A, Kapel L (1989) Independent evaluation of a multidisciplinary rehabilitation program for chronic low back pain. Neurosurgery 25 6: 877
Delitto D, Rose SJ, Crandell CC, Strube MJ (1991) Reliability of isokinetic measurements of trunk muscle performance. Spine 16: 800
Deyo RA (1988) Measuring the functional status of patients with low back pain. Arch Phys Med Rehabil 69: 1044
Deyo RA (1993) Practise variations treatment fads, rising disability. Spine 18: 2153
Deyo RA, Andersson G, Bombardier C, Cherkin DC, Keller RB, Lee CK, Liang MH, Lipscomb B, Shekelle P, Spratt KF, Weinstein JN (1994) Outcome measure for studying patients with low back pain. Spine 19: 2032
Dolce JJ, Crocker MF, Moletteire C, Doleys DM (1986) Exercise quotas, anticipatory concern ans self-efficiacy expectancies in chronic pain. Pain 24: 365
Dopf CA, Mandel SS, Geiger DF, Mayer PJ (1994) Analysis of spine motion variability using a computerized goniometer compared to physical examination. Spine 19: 586
Dvorak, J, Panjabi MM, Chang DG, Theiler R, Grob DC (1991) Functional radiographic diagnosis of the lumbal spine. Spine 16: 562
Ensink FB, Saur PM, Frese K, Seeger D, Hildebrandt J (1996) Lumbar range motion II. Influence of time of day and individual factors on the measurements. Spine 21: 1399
Estlander AM, Mellin G, Vanharanta H, Hupli M (1991) Effects and follow-up of a multimodal treatment programm including intensive physical training for low-back pain patients. Scand J. Rehabil Med 23: 97
Fairbank CJ, Davies JB, Couper J, O’Brien JP (1980) The Oswestry low back pain disability questionaire. Physiotherapy 66: 271
Fenty A, Kumar S (1992) Isocinetic trunk strength and lumbarsacral range of motion in elite female field hockey players reporting low back pain. J Orthop Sports Phys Ther 16: 129
Ferrari M, Ensink FBM, Steinmetz U, Straub A, Ahrens P, Thegeder H, Krüger A (1994) Adaptation isokinetischer Kraftparameter in der Grundausbildung. Wehrmed Monatsschr 2: 42
Flor H, Turk DC (1988) Rheumatoid arthritis and back pain: predicting pain and disability from cognitive variables. J Behav Med 11: 251
Flor H, Fydrich T, Turk DC (1992) Efficiacy of multidisciplinary pain treatment centers: a meta-analytic review. Pain 49: 221
Fordyce WE (1976) Behavioral methods for chronic pain and illness. CV Mosby, St. Louis
Fritz C (1990) Rückenproblem—Ursache und Wirkung. Eine Erklärung und eine partielle Lösung. Krankengymnastik 42: 636
Frymoyer JW (1992) Predicting disability from low back pain. Clin Orthop 279: 101
Frymoyer JW (1993) Quality: an international challenge to the diagnosis and treatment of disorders of the lumbar spine. Spine: 2147
Gatchel RJ, Mayer TG, Hazard RG, Rainville J, Mooney V (1992) Editorial: functional restoration. Pitfalls in evaluating efficacy. Spine 17/8: 988
Gerbershagen U (1986) Organisierte Schmerzbehandlung. Der Internist 27: 459
Grimby G (1982) Isokinetic training. Int J Sports Med 3: 61
Groen GJ, Baljet B, Drukker J (1990) Nerves and nerve plexuses of the human vertebral column. Am J Anat 188: 282
Gundewall B, Liljeqvist M, Hansson T (1993) Primary prevention of back symptoms and absence from work. A prospective randomized study among hospital employees. Spine: 587
Haldemann S (1990) Presidental Adress, North American Spine Society: Failure of the pathology model to predict back pain. Spine 15: 718
Hansen FR, Bendix T, Skov P, Jensen CV, Kristensen JH, Krohn L, Schioeler H (1993) Intensive, dynamic back-muscle exercises, conventional physiotherapy or placebo-control treatment of low-back pain. Spine 18: 98
Hasten DL, Johnston FA Lea RD (1995) Validity of the applied rehabilitation concepts (ARCON) system for lumbar range of motion. Spine 20: 1279
Hazard RG, Reid S, Fenwick JW, Reeves V (1988) Isokinetic trunk and lifting strength measurements: variability as an indicator of effort. Spine 13: 54
Hazard RG, Fenwick JW, Kalish SM (1989) Functional restoration with behavioral support: A one-year prospective study of patients with chronic low-back pain. Spine 14: 157
Hazard RG, Bendix A, Fenwick JW (1991) Disability exaggeration as a predictor of functional restoration outcomes for patients with chronic low-back pain, Spine 16: 1062
Hazard RG, Reeves V, Fenwick JW, Fleming BC, Pope MH (1993) Test-retest variation in lifting capacity and indices of subject effort. Clin Biomech 20
Herron LD, Turner J (1985) Patient selecton for lumbar laminectomy and discectomy with a revised objective rating system. Clin Orthop 199: 145
Hildebrandt J (1987) Diagnostik und Klassifikation chronischer “idiopathischer” Rückenschmerzen. Habilitationsschrift, Fachbereich Medizin, Universität Göttingen
Hildebrandt J, Pfingsten M, Frese K, Ensink FB, Saur P (1995) Reliabilität und Validität der Inklinometertechnik zur Messung der LWS-Beweglichkeit. Manuelle Med 33: 11
Hitselberger WE, Witten RM (1968) Abnormal myelogramm in asymptomatic patients. J Neurosurg 28: 204: 206
Hollmann W, Hettinger T (1990) Sportmedizin—Arbeits- und Trainingsgrundlagen, 3 Aufl, Schattauer, Stuttgart New York
Hollmann W, Rost R, Mader A, Liesen H (1992) Altern, Leistungsfähigkeit und Training. Dtsch Ärztebl 38: 1930
Hyytätinen K, Salminen JJ, Suvitie T, Wickström G Pentii J (1991) Reproducibility of nine testts to measure spinal mobility and muscle strength Scand J Rehab Med 23: 3
Jerome JA, Hunter KH, Gorden P, McKay (1991) A new robust index for measuring isokinetic trunk flexion and extension. Outcome from a regional study. Pain 16: 804
Jirout J (1957) The normal mobility of the lumbasacral spine. Acta Rad 3: 345
Kohles S, Barnes D, Gatchel RJ, Mayer TG (1990) Improved physical performance outcomes after functional restoration treatment in patients with chronic low-back pain. Early versus recent training results. Spine 15: 1321
Krüger A (1972) Die Anwendungsmöglichkeiten des isokinetischen Krafttrainings für die Leichtathletik. Die Lehre der Leichtathletik 16: 558
Langrana NA, Lee CK (1984) Isokinetic evaluation of trunk muscles. Spine 9: 171
Lehmann TR, Brand RA, Gorman TW (1983) A low back rating scale. Spine 8: 308
Lichter RL, Hewson JK, Radke SJ, Blum M (1984) Treatment of chronic low-back pain. A community-based comprehensive return-to-work physical rehabilitation program. Clin Orthop 190: 115
Lindström I, Öhlund C, Eek C, Wallin L, Peterson LE, Fordyce WE, Nachemson AL (1992) The effect of graded activity on patients with subacute low back pain. Phys Ther 72: 279
Matheson LN, Mooney V, Grant E et al. (1995) A test to measure lift capacity of physically impaired adults: part 1-development and reliability testing. Spine 20: 2119
Matheson LN, Mooney V, Holmes D (1995) A test to measure lift capacity of physically impaired adults: part 2-reactivity in a patient sample. Spine 20: 2130
Mayer TG, Tencer AF, Kristoferson S, Mooney V (1984) Use of noninvasive techniques for quantification of spinal range-of-motion in normal subjects and chronic low-back dysfunction patients. Spine 9: 588
Mayer TG, Smith S, Keeley J, Mooney V (1985) Quantification of lumbar function. Spine 10: 765
Mayer TG, Gatchel RJ, Kishina N, Keeley J, Mayer H, Capra et al (1986) A prospective short-term study of chronic low back patients utilizing novel objective functional measurement. Pain 25: 53
Mayer TG, Gatchel RJ, Mayer H, Kishino ND, Keeley J, Mooney V (1987) A prospective two-year study of functional restoration in industrial low back injury. JAMA 258: 1763
Mayer TG, Gatchel RJ (1988) Functional restoration for spinal disorders: the sports medicine approach. Lea & Febiger, Philadelphia
Mayer TG, Tabor J, Bovasso E, Gatchel RJ (1994) Physical propress and residual impairment quantification after functional restoration. Part I: lumbar mobility. Spine 19: 389
Mayer T, Gatchel R, Betancur J, Bovasso E (1995) Trunk muscle endurance measurement. Spine 20: 920
McNeil T, Warwick D, Andersson G, Schultz A (1980) Trunk strengths in attempted flexion, extension and lateral bending in healthy subjects and patients with low back disorders. Spine 5: 529
Moffroid M, Whipple R, Hofkosh J, Lowman E, Thistle H (1969) A study of isokinetic exercise. Phys Ther 49: 735
Moll J, Wrigth V (1976) Measurement of spinal movement. The lumbar spine and back pain Grune & Stratton, New York
Nachemson AL (1992) Newest knowledge of low-back pain. Spine 279: 8
Newton M, Waddell G (1993) Trunk strength testing with iso-machines. Spine 18: 801
Nice DA, Riddle DL, Lamb RL, Mayhew TP, Rucker K (1992) Intertester reliability of judgments of the presence of trigger points in patients with low back pain. Arch Phys Med Rehabil 73: 893
Panjabi MM, White AH (1980) Basic biomechanics of the spine. Neurosurgery 7: 76
Panzer DM (1992) The reliability of lumbar motion palpation. J Manipulative Physiol Ther 15: 518
Pearcy MJ, Portek I, Shepherd J (1985) The effect of low back pain on lumbar spinal movements measured by three-dimensional X-ray analysis. Spine 10 150
Pollard CA (1984) Preliminary validity study of pain disability index. Percept Mot skills 59: 974
Pollock ML, Leggett SH, Graves JE, Jones A, Fulton M, Cirulli J (1989) Effects of resistance training on lumbar extension strength. Am Sports Med 17: 624
Portek I, Pearcy MJ, Reader GP (1983) Correlation between radiographic and clinical measurement of lumbar spine movements. Br J Rheumatol 22: 197
Potter NA, Rothstein JM (1985) Intertester reliability for selected clinical tests of the sacroiliac joint. Phys Ther 65: 1671
Rainville J, Ahern DK, Phalen L, Childs LA, Sutherland R (1992) The association of pain with physical activities in chronic low back pain. Spine 17: 1060
Rantanen P, Airaksinen O (1992) Geringe Übereinstimmung sogenannter Iliosakraltests bei Patienten mit ankylosierender Spondylitis. Manuelle Med 30: 2
Raspe HH, Wasmus A, Greif G et al. (1990) Rückenschmerz in Hannover. Aktuel Rheumatol 15: 32
Reid S, Hazard RG, Fenwick JW (1991) Isokinetic trunk-strength deficits in people with and without low back pain: a comparative study with consideration of effort. J Spinal Disorders 4: 68
Report of the Quebec Task Force on Spinal Disorders (1987) Scientific approach to the assessment and management of activity-related spinal disorders. A monograph for clinicians. Spine 12 [Suppl]
Richter T, Lawall J (1993) Zur Zuverlässigkeit manualdiagnostischer Befunde. Manuelle Med 31: 1
Rothstein JM, Lamb RL, Mayhew TP (1987) Clinical use of isokinetic measurements. Critical issues. Phys Ther 67: 1840
Rudy TE, Boston JR, Lieber SJ, Kubinsky JA, Delitto A (1995) Body motion patterns during a repetitive wheel rotation task: a comparative study of normal subjects and low back pain patients. Spine 20: 2547
Saal JS (1995) The role of inflammation in lumbar pain. Spine 20: 1821
Saur PM, Ensink FB, Frese K, Seeger D, Hildebrandt J (1996) Lumbar range of motion I: reliability and validity of the inclinometer technique as clinical measurement of trunk flexibility. Spine 21: 1332
Saur PM, Koch D, Ensink FB et al. (submitted) Interrater-reliability of the isokinetic LIDO-Back system. Clin Sci
Saur PM, Pfingsten M, Kasi B et al. (submitted) Development of the endurance status of patient with chronic low back pain. Arch Phys Med Rehabil
Saur PM, Pfingsten M, Ensink FB et al. (im Druck) Interrater-Untersuchungen zur Reliabilitätsüberprüfung somatischer Befunde. Die Rehabilitation
Shirley FR, O’Connor P, Robinson ME, MacMillan M (1994) Comparison of lumbar range of motion using three measurement devices in patients with chronic low back pain. Spine 19: 779
Simmons ED, Guyer RD, Graham-Smith A, Herzog R (1995) Contemporary concepts in spine care. Radiographic assessment for patients with low back pain. Spine 20: 1839
Spring H, Kunz HR, Schneider W, Tritschler T, Unold E (1990) Kraft-Theorie und Praxis. Thieme, Stuttgart
Steinmetz U (1991) Isokinetische Untersuchungen zur Kraft des Rückens. Magisterarbeit am Fachbereich Sozialwissenschaften, Göttingen
Steinmetz U, Straub A, Hildebrandt J, Ensink FBM (1992) Die Bedeutung der Kraftleistungsfähigkeit der Rumpfmuskulatur für die Pathogenese chronischer Rückenschmerzen (Teil II), Gesundheitssport Sporttherapie 8: 4
Steinmetz U, Straub A (1993) Sport und sportwissenschaftliches Training bei Wirbelsäulenbeschwerden. Dissertation am Fachbereich Sozialwissenschaften der Universität Göttingen
Stevenson JM, Andrew GM, Bryant JT, Greenhorn DR, Thomson JM (1989) Isoinertial tests to predict lifting performance. Ergonomics 32: 157
Straub A (1991) Untersuchungen der isokinetischen Kraftleistungsfähigkeit an Gesunden und Patienten mit chronischen Rückenschmerzen. Magisterarbeit am Fachbereich Sozialwissenschaften, Göttingen
Straub A, Steinmetz U, Hildebrandt J, Ensink FB (1992) Die Bedeutung der Kraftleistungsfähigkeit der Rumpfmuskulatur für die Pathogenese chronischer Rückenschmerzen (Teil I). Gesundheitssport Sporttherapie 5: 4
Tait RC, Chibnall JT, Krause S (1990) The Pain Disability Index: psychometric properties. Pain 40: 171
Tanz SS (1953) Motion of the lumbar spine A roentgenologic study. Am J Roentgenol 69: 399
Thompson NN, Gould JA, Davies GJ, Ross DE, Proce S (1985) Descriptive measures of isokinetic trunk testing. J Orthop Sports Phys Ther 7: 43
Turk DC, Rudy TE (1991) Persistent pain and the injured worker: Integrating biomedical, psychological and behavioral factors. J Occup Rehabil 1: 159
Turk DC, Rudy TE (1991) Neclected topics in the treatment of chronic pain patients—relapse, noncompliance and adherence enhancement. Pain 44: 5
Turner Ja, Clancy S, McQuade KJ, Cardenas DD (1990) Effectiveness of behavioral therapy for chronic low back pain. J Consult Psych 58: 573
Van Deursen LLJM, Patijn J, Ockhuysen AL, Vortman BJ (1992) Die Wertigkeit einiger klinischer Funktionstests des Iliosacralgelenks. Manuelle Med 30: 43
Waddell G, Main CJ, Morris EW et al. (1982) Normality and reliability in the clinical assessment of backache. Br Med J 284: 1519
Waddell G, Main CJ (1984) Assessment of severity of low-back disorders. Spine 9: 204
Wiesel SW, Tsourmas N, Feffer HL, Citrin CM, Patronas M (1984) A study of computer-assisted tomography. I. Incidence of positive CAT scans in an asymptomatic group of patients. Spine 9: 549
Author information
Authors and Affiliations
Additional information
Das diesem Bericht zugrundeliegende Vorhaben wurde mit Mitteln des Bundesministers für Bildung, Wissenschaft, Forschung und Technologie unter dem Kennzeichen 0701506 gefördert.
An dieser Studie waren des weiteren beteiligt: Beate Choroba-Mehnen, Franz-Bernd Ensink, Carmen Franz, Tülün Fleer, Eva-Maria Katiofsky, Iris Padur, Andrea Reiche, Gudrun Schwibbe und Stefani v.Westernhagen
Rights and permissions
About this article
Cite this article
Saur, P., Hildebrandt, J., Pfingsten, M. et al. Das Göttinger Rücken Intensiv Programm (GRIP)—ein multimodales Behandlungsprogramm für Patienten mit chronischen Rückenschmerzen, Teil 2. Schmerz 10, 237–253 (1996). https://doi.org/10.1007/s004820050046
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s004820050046