the need for conservative spinal interventions is increasing , corresponding to the increasing number of spinal disorders .
the literature describes multimodal therapy programs as successful therapy options in the treatment of acute and chronic low back pain ( lbp).13 the multimodal outpatient program at the university of ulm department of orthopaedics has provided an intense multimodal treatment on an outpatient basis for several years .
it combines group therapy with individual approaches , pain management , medication , spinal injection procedures , physiotherapy , medical training therapy , spa , massage , transcutaneous electrical nerve stimulation ( tens ) , ergotherapy , traction , and back school .
such a constellation of experts provides an intense level of therapy for the patient . despite many reports in the literature
, this study does not use the term  nonspecific  low back pain , but , rather , aims to determine a specific diagnosis based on clinical examination , radiography , and magnetic resonance tomography ( mrt ) .
the purpose of this study is to compare the short - term outcomes between patients suffering from sciatica due to a discus intervertebralis herniation and those suffering from low back pain caused by facet joint disease after 3 weeks of intense multimodal outpatient pain management program .
the duration of the program is 3 weeks , occurring daily between 8 am and 5 pm .
it combines a broad spectrum of active and passive therapy elements , performed in groups as well as on an individual basis .
the core elements of the therapy regime are medical , physiotherapy , and psychological , using a collaborative , interdisciplinary , and nonhierarchical team approach .
an experienced orthopedic surgeon and an anesthesiologist are responsible for the medical treatment , indication , modification in medication or treatment regime , further diagnosis , and interventional pain management .
between five and seven experienced physical therapists provide group and individual exercise , back school , manipulation , massage , spa therapy , tens , superficial heat application , traction , ultrasonography , and physical relaxation techniques .
a separate ergotherapy group is included in the treatment regime to improve patients occupational and private functionality .
an experienced psychologist is responsible for psychological therapy ( psychosomatic treatment and psychotherapy ) in a group setting .
individual psychological therapy is optional , but is utilized by an increasing number of patients .
the team discusses each patient s history , therapy approach , and progress in 23 meetings per week .
table 1 describes the separate components of the treatment regime and the frequency of each component s application .
the duration of the program is 3 weeks , occurring daily between 8 am and 5 pm .
it combines a broad spectrum of active and passive therapy elements , performed in groups as well as on an individual basis .
the core elements of the therapy regime are medical , physiotherapy , and psychological , using a collaborative , interdisciplinary , and nonhierarchical team approach .
an experienced orthopedic surgeon and an anesthesiologist are responsible for the medical treatment , indication , modification in medication or treatment regime , further diagnosis , and interventional pain management .
the orthopedic surgeon supervises each patient s progress two times per day . between five and seven experienced physical therapists provide group and individual exercise , back school , manipulation , massage , spa therapy , tens , superficial heat application , traction , ultrasonography , and physical relaxation techniques .
a separate ergotherapy group is included in the treatment regime to improve patients occupational and private functionality .
an experienced psychologist is responsible for psychological therapy ( psychosomatic treatment and psychotherapy ) in a group setting .
individual psychological therapy is optional , but is utilized by an increasing number of patients .
the team discusses each patient s history , therapy approach , and progress in 23 meetings per week .
table 1 describes the separate components of the treatment regime and the frequency of each component s application .
one hundred fifty - six ( out of 261 ) patients who underwent the intense interdisciplinary treatment between 2009 and 2011 were included in this retrospective study .
the inclusion criteria were as follows : a definitive diagnosis of lumbar disc herniation with sciatica ( n = 107 ) or facet joint arthritis with low back pain ( n = 49 ) , based on clinical and radiographic ( plain radiograms and mrt ) examination .
the radiographic criteria proposed by lane et al4 were used to analyze the plain radiographs .
the criteria outlined by pfirrmann et al5 were used to analyze the t2-weighted sagittal magnetic resonance imaging ( mri ) scans for lumbar disc degeneration , in combination with disc extrusion in the mri and clinical findings of persistent or intermittent nerve root entrapment .
finally , the criteria proposed by weishaupt et al were used to analyze the mri imaging for lumbar facet joint degeneration in combination with changes in plain radiographs ( sclerosis , hypertrophy ) and clinical findings of local or pseudoradicular lumbar pain.6 no other spinal diseases or systemic disorders contributed to the symptoms .
patients with overlapping symptoms and multilocular pathology ( spondylarthritis and discus hernia ) who could not be characterized precisely after spinal injections into one of the two subgroups were excluded from the retrospective analysis .
the duration of symptoms was at least 12 weeks and every patient received standard therapy before entering the program .
every patient enrolled in the study was treated for 3 weeks in the program and signed an informed consent about the use of the datasets ( history , numerical rating scale [ nrs ] , and oswestry disability questionnaire [ odq ] ) acquired at the baseline and at the end of the therapy regime .
the exclusion criteria were infection , severe instability , pregnancy , age under 18 years , fracture , anticoagulation , myelopathy , somatoform disease , substance abuse , severe cardiopulmonary alteration , weak overall fitness , paresis , and incompliance .
the mean pain intensities of sciatica and lbp ( low back pain ) were documented using the 10-point nrs . in cases of coexistence of lbp and sciatica ,
both tools are validated and frequently used to assess the outcome of surgical and nonsurgical treatments for low back pain.7 the mean nrs reduction and odi ( oswestry disability index ) improvement were analyzed with statistical software ( spss statistics 17.0 ; ibm corporation , armonk , ny ) .
first , the normal ( gaussian ) distribution of variables was excluded using a histogram , the kolmogorov - smirnov test with a lilliefors significance correction , and the shapiro  wilk test .
whitney test ( u - test ) and the kolmogorov- smirnov test ( z - test ) to identify unpaired variables and a significant difference between the discus hernia cohort and the facet joint disease group.8,9 the sample power size was calculated with a t - test analysis ( post hoc one - tailed analysis for means ) .
the results of the z - test were reproduced with minitab 16 ( minitab inc , state college , pa ) .
one hundred fifty - six ( out of 261 ) nrs and odq outcomes were analyzed ( sciatica in lumbar discus hernia group , n = 107 ; low back pain in spondylarthrosis , n = 49 ) .
a sample size power of 0.9985 was calculated using a t - test analysis ( post hoc one - tailed analysis for means , effect size d = 0.8 ,  = 0.05 , critical t < 154 > = 1.6548 , delta = 4.6379 ) .
the mean reduction of nrs was calculated to be 4.31 points in the discus hernia group ( mean = 4.31 , 95% ci : 4.66 to 3.96 , sd = 1.82 ) and 4.43 in the facet joint disease group ( mean = 4.43 , 95% ci : 5.00 to 3.85 , sd = 2.00 ) ( see figure 1a ) .
the mean disability reduction ( measured by odi ) was calculated to be 10.47% in the discus hernia group ( mean = 10.47% , 95% ci : 12.58% to 8.36% , sd = 10.94 ) , and 10.88% for the facet joint disease group ( mean = 10.88% , 95% ci : = 13.84% to 7.92% , sd = 10.31 ) ( see figure 1b ) .
neither of the groups presented a gaussian distribution of variables in their outcomes ( graphical analysis histogram , kolmogorov - smirnov test with a lilliefors significance correction = 0.000 , 0.004 ; shapiro 
whitney u - test and the z - test were used to calculate the significance of the difference between the results in both groups ( h0-hypothesis : the results in the improvement of pain self - assessment and functionality in both groups were equal ) .
the hypothesis of equality ( h0 ) was accepted after calculating a two - tailed significance of 0.757 for pain reduction , 0.702 for odi reduction using the mann 
whitney u - test , a two - tailed significance of 1.000 for pain reduction , and 0.997 for odi reduction using the kolmogorov  smirnov z - test .
there were no complications or dropouts during the therapy regime in either of the groups .
most unimodal treatments fail to restore functionality and adequately reduce pain.10 one reason for this failure is the biopsychosocial aspect of chronic pain , which is not addressed in unimodal therapy . with its focus on functional restoration ,
multimodal treatment is a promising option for patients with chronic lbp.11 the results of this comparative study demonstrate equal short - term results in the intense interdisciplinary treatment of patients with lumbar discus herniation with sciatica and patients with lbp due to facet joint disease . despite the efficacy of intense interdisciplinary treatment regimes ,
there is a lack of research on how this method affects specific spinal disorders . according to the results of this study ,
we conclude that patients suffering from sciatica due to intervertebral disc herniation and patients with chronic back pain due to facet joint disease have similar short - term results in response to intense interdisciplinary treatment .
compared to the results for chronic lbp treatment regimes presented in the literature , both groups presented good clinical outcomes.11 despite many misleading reports in the literature , this study does not use the term  nonspecific  lbp , but , rather , aims to determine a specific diagnosis based on clinical examination , radiography , and mrt.1214 although there was no significant difference in the outcomes from both groups , the results do not justify the use of nonspecific diagnoses .
the results of this study must be interpreted carefully , because imaging and examination findings do not always correlate with symptoms in spinal disorders , nor do they correspond to subjective pain intensity.15,16 therefore , forcing a specific spinal - disorder diagnosis is problematic .
wrong diagnoses may lead to overdiagnosis , labeling effects experienced by the patient , and , ultimately , further chronification of pain.17 on the other hand , specific anatomical diagnoses have direct therapeutic implications in orthopedics , especially for the use of spinal injection procedures ( epidural , periradicular or facet joint injections).18 in addition to the therapeutic benefit of symptom control , image - guided injections also contribute to higher diagnostic accuracy ( eg , verification of facetogenic versus radicular pain).19,20 reports in the literature conclude that 67%75% of lbp cases can be accurately diagnosed as discogenic , facetogenic , or sacroiliac pain using image - guided injections.2123
 the literature describes multimodal pain - management programs as successful therapy options in the conservative treatment of chronic low back pain . yet 
 , the intensity and inclusion criteria of such programs remain debatable . in many studies , the pain originating from spinal structures 
 is described as nonspecific low back pain  a diffuse diagnosis without serious implications . 
 the purpose of this study is to compare the short - term outcomes between patients suffering from sciatica due to a discus intervertebralis herniation and those suffering from low back pain caused by facet joint disease after 3 weeks of treatment in an intense multimodal outpatient program in the department of orthopaedic surgery at the university hospital . 
Introduction
Treatment regime specifications
Materials and methods
Results
Discussion