The focus of this qualitative study was on modifiable aspects of rehabilitation that may improve treatment outcome. Many patients with a Southeast European cultural background do not accept that psychological aspects may contribute to LBP. Communication problems impairing the rehabilitation process are related to limited German language ability, as well as cultural differences in communication. Most patients have high treatment expectations and are disappointed when these are not fulfilled. Moreover, patients' goals do not match those of health professionals because patients prefer pain-centred treatment and reduce activities that cause pain. Although avoiding activities that increase pain initially relieves pain and makes patients "feel good", the consequence is that activity tolerance decreases and pain is eventually felt at lower intensities of activity. Patients are, thus, caught in a vicious circle, also known as the "feel good trap". As a result, activity should be gradually increased in spite of pain because improving activity tolerance decreases pain in the long term. This message is repeatedly communicated to patients but, regardless of language and culture, many patients with chronic pain find it difficult to understand, accept and adopt.
Based on current evidence, multidisciplinary rehabilitation aiming at increasing activity is the treatment of choice, even though treatment is accompanied by discomfort and even a pain increase. Discomfort accompanies treatment of chronic pain and many other treatments aiming at changing behaviour such as losing weight by changing eating habits, stopping smoking, and changing one's lifestyle to improve physical fitness. Avoiding necessary efforts and short-term discomfort are frequent barriers to successful treatment.
If none of the patients were to benefit from movement in spite of pain, treatment would seem unethical. The majority of patients who increasingly use active coping strategies manage to decrease disability and return to work. This supports the applied treatment concept and justifies its use.
Many issues identified in this study may, after all, not only be cultural. Many factors are associated with social background . To give two examples, both lower education and heavy manual work are associated with poorer outcome, independent of cultural background . Some researchers also questioned whether cultural background is predictive for outcome and concluded that social background is more important than culture . Despite these considerations, it seems plausible that cultural factors exist.
Several barriers to better rehabilitation outcomes are more pronounced in patients from Southeast Europe, for instance language problems hindering communication between patients and health professionals, patients' treatment expectations focusing on help by physicians and health professionals, and passive coping strategies. For many patients from Southeast Europe, their family and relatives play an important role. During inpatient rehabilitation, patients miss their families, as they are not used to being separated from them for several weeks.
Study strengths and limitations
Strengths of this study include semi-structured in-depth interviews that were conducted by a native speaker. The triangulation of results from the semi-structured in-depth interviews with patients and health professionals, and scientific literature increases the reliability and validity of the results. The results are highly relevant as they aim at inducing a change in rehabilitation practice.
Weaknesses of the study are that we conducted only 13 patient interviews. Saturation may not have been reached and information may have been missed. Furthermore, we only contacted patients in one rehabilitation centre and only patients from the region of the former Yugoslavia. Therefore, it might be possible that the information would be different, if patients were interviewed in other rehabilitation centres. The conclusions drawn from our research are strictly only valid for patients from the former Yugoslavia. People from other countries and ethnic groups may have other ideas and beliefs regarding treatments. Our findings do not allow causal interpretations between cultural factors and treatment outcome for two reasons. Firstly, this is a qualitative study that was designed to develop hypotheses on how the treatment of patients from Southeast Europe can be improved. Secondly, the cross-sectional design of this study is inadequate for causal inferences as it is unknown whether the proposed causal factor actually preceded the effect. Finally, a comparison group is lacking.
It is important to implement return to work management early, including return to adapted work to improve rehabilitation in patients with a South European cultural background. Special emphasis must be given to the process of formulating goals by spending more time with patients to identify barriers to goal attainment. We further propose the involvement of patients' families and increased use of interpreters. Information on the return to work process should also include the financial aspects of unemployment and disability. During rehabilitation, more attention should be given to patients developing outlooks for the future.