Die Rehabilitation
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Chronic back pain has a high personal impact, is frequent and of outstanding economical relevance. Analysis of the international literature indicates strong or moderate evidence for the effectiveness of multimodal multidisciplinary team care of chronic back pain. Our review aims at a complete review and critical appraisal of German studies of inpatient medical rehabilitation. ⋯ In the era of evidence based medicine, inpatient rehabilitation has to show its usefulness, necessity and efficiency as any other type of health care. For the German system of inpatient rehabilitation of chronic back pain available evidence is not conclusive, due to a lack of randomised controlled studies. The prevailing design of observational cohort studies has severe limitations in proving a causal relationship between outcomes and intervention. The international literature however provides more valid evidence in favour of the multimodal multidisciplinary intervention in chronic back pain. Under the assumption of a "class effect" of medical rehabilitation the German data seem to corroborate the conclusions drawn from international studies.
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In this paper, the concept of Shared Decision Making, i. e. the participation of the patient regarding the selection of therapeutic goals and treatment options, is presented. The degree of patient participation in medical decisions varies widely across different models of the physician-patient relationship. According to the paternalistic model, the physician knows best what is in the patient's interest; patient participation is limited. ⋯ Both physicians and patients require the ability to make shared decisions. Structural restraints include time and institutional inflexibility. To conclude, shared decision making is a promising approach to enhance patient participation in rehabilitative care.