Effectiveness of behavioural medical rehabilitation under real-life conditions in Germany: A propensity-score matched analysis





rehabilitation, programme evaluation, mental health comorbidity, work ability, health service research


Objectives: In Germany, behavioural medical rehabilitation programmes have been implemented for patients with musculoskeletal disorders and additional mental health comorbidity. The aim of this cohort study is to assess the relative effectiveness of behavioural medical rehabilitation under real-life conditions.

Design: Participants received either a common or behavioural medical rehabilitation programme. Propensity score matching was used to provide balanced samples of both groups (German Clinical Trials Register: DRKS00016404).

Participants: A total of 360 patients treated in behavioural medical rehabilitation were compared with 360 matched controls. The mean age of study participants was approximately 53.5 years (standard deviation (SD)=7.0 years) and 74.0% were women.

Results: No significant and clinical meaningful differences were found in return to work, applications for disability pension, and the number of patients receiving social security benefits in the year after rehabilitation. However, participants in behavioural medical rehabilitation reported better self-rated work ability, physical functioning and self-management skills, and decreased pain disability and fear-avoidance beliefs 10 months after rehabilitation. Standardized effect sizes were between 0.13 and 0.22.

Conclusion: Behavioural medical rehabilitation had no clinical meaningful effect on maintaining and restoring work ability. However, behavioural medical rehabilitation affected pain and disease management skills 10 months after completing the rehabilitation programme.


Download data is not yet available.


Woolf AD, Erwin J, March L. The need to address the burden of musculoskeletal conditions. Best Pract Res Clin Rheumatol 2012; 26: 183–224.

Schmidt CO, Raspe H, Pfingsten M, Hasenbring M, Basler HD, Eich W, et al. Back pain in the German adult population: prevalence, severity, and sociodemographic correlates in a multiregional survey. Spine 2007; 32: 2005–2011.

Deutsche Rentenversicherung Bund. Rentenversicherung in Zeitreihen 2019. [Pension insurance in time series 2019.] Berlin: Deutsche Rentenversicherung Bund; 2019 (in German).

Schmidt C, Bernert S, Spyra K. Zur Relevanz psychischer Komorbiditäten bei chronischem Rückenschmerz: Häufigkeitsbild, Erwerbsminderungsrenten und Reha-Nachsorge im Zeitverlauf der Reha-Kohorten 2002–2009. [Concerning the impact of psychological comorbidity for chronic back pain: frequency, reduced earning capacity pension and rehabilitation aftercare in the course of the rehabilitation cohorts 2002–2009.] Rehabilitation 2014; 53: 384–389 (in German).

Aartun E, Axén I, Mior S, Røe Y, Hondras M, Kretz L, et al. Contextualizing the lived experiences of patients with low back pain from different countries according to the ICF framework. J Rehabil Med 2021; 53: jrm00189.

Deutsche Rentenversicherung Bund. Positionspapier der Deutschen Rentenversicherung zur Bedeutung psychischer Erkrankungen in der Rehabilitation und bei Erwerbsminderung. [Position paper of the German Pension Insurance on the importance of mental disorders in rehabilitation and in work disability.] Berlin: Deutsche Rentenversicherung Bund; 2014 (in German).

Deutsche Rentenversicherung Bund. Anforderungsprofil der Deutschen Rentenversicherung Bund für die verhaltensmedizinisch orientierte Rehabilitation (VOR). [Guideline for behavioral medical rehabilitation (BMR) by the Federal German Pension Insurance.] 2nd edn. Berlin: Deutsche Rentenversicherung Bund; 2016 (in German).

Mangels M, Schwarz S, Worringen U, Holme M, Rief W. Evaluation of a behavioral-medical inpatient rehabilitation treatment including booster sessions: a randomized controlled study. Clin J Pain 2009; 25: 356–364.

Hampel P, Tlach L, Gräf T, Krohn-Grimberghe B, Mantel F, Mohr B. Zur Wirksamkeit eines Trainings zur Depressionsbewältigung für Patienten mit chronisch unspezifischem Rückenschmerz in der stationären Rehabilitation – Eine 1-Jahres-Follow up-Studie. [On the effectiveness of depression coping training for patients with chronic nonspecific back pain in inpatient rehabilitation – a 1-year follow-up study.] DRV-Schriften 2009; 83: 322–325 (in German).

Bethge M, Müller-Fahrnow W. Wirksamkeit einer intensivierten stationären Rehabilitation bei muskuloskelettalen Erkrankungen: systematischer Review und Meta-Analyse. [Efficacy of intensified inpatient rehabilitation in musculoskeletal disorders: systematic review and meta-analysis.] Rehabilitation 2008; 47: 200–209 (in German).

Hampel P, Köpnick A, Roch S. Psychological and work-related outcomes after inpatient multidisciplinary rehabilitation of chronic low back pain: a prospective randomized controlled trial. BMC Psychol 2019; 7: 6.

Glasgow RE, Lichtenstein E, Marcus AC. Why don’t we see more translation of health promotion research to practice? Rethinking the efficacy-to-effectiveness transition. Am J Public Health 2003; 93: 1261–1267.

Des Jarlais DC, Lyles C, Crepaz N. Improving the reporting quality of nonrandomized evaluations of behavioral and public health interventions: the TREND statement. Am J Public Health 2004; 94: 361–366.

Bethge M, Markus M, Streibelt M, Gerlich C, Schuler M. Effects of nationwide implementation of work-related medical rehabilitation in Germany: propensity score matched analysis. Occup Environ Med 2019; 76: 913–919.

Neuderth S, Schwarz B, Gerlich C, Schuler M, Markus M, Bethge M. Work-related medical rehabilitation in patients with musculoskeletal disorders: the protocol of a propensity score matched effectiveness study (EVA-WMR, DRKS00009780). BMC Public Health 2016; 16: 804.

Kuijer PP, Gouttebarge V, Wind H, van Duivenbooden C, Sluiter JK, Frings-Dresen MH. Prognostic value of self-reported work ability and performance-based lifting tests for sustainable return to work among construction workers. Scand J Work Environ Health 2012; 38: 600–603.

Ilmarinen J. The Work Ability Index (WAI). Occup Med 2007; 57: 160.

Kristensen TS, Hannerz H, Hogh A, Borg V. The Copenhagen Psychosocial Questionnaire - a tool for the assessment and improvement of the psychosocial work environment. Scand J Work Environ Health 2005; 31: 438–449.

Nuebling M, Hasselhorn HM. The Copenhagen Psychosocial Questionnaire in Germany: from the validation of the instrument to the formation of a job-specific database of psychosocial factors at work. Scand J Public Health 2010; 38: 120–124.

Wirtz M, Farin E, Bengel J, Jäckel WH, Hammerer D, Gerdes N. IRES-24 patient questionnaire: development of the short form of an assessment instrument in rehabilitation by means Mixed-Rasch analysis. Diagnostica 2005; 51: 75–87.

Lowe B, Kroenke K, Grafe K. Detecting and monitoring depression with a two-item questionnaire (PHQ-2). J Psychosom Res 2005; 58: 163–171.

Kroenke K, Spitzer RL, Williams JB, Lowe B. The Patient Health Questionnaire Somatic, Anxiety, and Depressive Symptom Scales: a systematic review. Gen Hosp Psychiatry 2010; 32: 345–359.

Von Korff M, Ormel J, Keefe FJ, Dworkin SF. Grading the severity of chronic pain. Pain 1992; 50: 133–149.

Klasen BW, Hallner D, Schaub C, Willburger R, Hasenbring M. Validation and reliability of the German version of the Chronic Pain Grade questionnaire in primary care back pain patients. Psychosoc Med 2004; 1: Doc07.

Pfingsten M, Kroner-Herwig B, Leibing E, Kronshage U, Hildebrandt J. Validation of the German version of the Fear-Avoidance Beliefs Questionnaire (FABQ). Eur J Pain 2000; 4: 259–266.

Kent P, Mirkhil S, Keating J, Buchbinder R, Manniche C, Albert HB. The concurrent validity of brief screening questions for anxiety, depression, social isolation, catastrophization, and fear of movement in people with low back pain. Clin J Pain 2014; 30: 479–489.

Osborne RH, Elsworth GR, Whitfield K. The Health Education Impact Questionnaire (heiQ): an outcomes and evaluation measure for patient education and self-management interventions for people with chronic conditions. Patient Educ Couns 2007; 66: 192–201.

Mittag O, Raspe H. Eine kurze Skala zur Messung der subjektiven Prognose der Erwerbstätigkeit: Ergebnisse einer Untersuchung an 4279 Mitgliedern der gesetzlichen Arbeiterrentenversicherung zu Reliabilität (Guttman-Skalierung) und Validität der Skala. [A brief scale for measuring subjective prognosis of gainful employment: findings of a study of 4279 statutory pension insurees concerning reliability (Guttman Scaling) and validity of the scale.] Rehabilitation 2003; 42: 169–174 (in German).

Attkisson CC, Zwick R. The client satisfaction questionnaire. Psychometric properties and correlations with service utilization and psychotherapy outcome. Evaluat Prog Plan 1982; 5: 233–237.

Schmitz N, Hartkamp N, Kiuse J, Franke GH, Reister G, Tress W. The Symptom Check-List-90-R (SCL-90-R): a German validation study. Qual Life Res 2000; 9: 185–193.

Küch D, Arndt S, Grabe A. UKS – Ultrakurzscreening psychosozialer Problemlagen zur bedarfsorientierten Angebotszuweisung in der somatischen Rehabilitation. [UKS - Ultra brief screening of psychosocial problems for needs-oriented service allocation in somatic rehabilitation.] Bonn: Deutscher Psychologen Verlag, 2011 (in German).

Lukasczik M, Wolf H-D, Gerlich C, Löffler S, Vogel H, Faller H, et al. Current state of vocationally oriented medical rehabilitation – a German perspective. Disabil Rehabil 2011; 33: 2646–2655.

Streibelt M, Bethge M. Prospective cohort analysis of the predictive validity of a screening instrument for severe restrictions of work ability in patients with musculoskeletal disorders. Am J Phys Med Rehabil 2015; 94: 617–626.

Austin PC. An introduction to propensity score methods for reducing the effects of confounding in observational studies. Multivariate Behav Res 2011; 46: 399–424.

Mitra R, Reiter JP. A comparison of two methods of estimating propensity scores after multiple imputation. Stat Methods Med Res 2016; 25: 188–204.

Cohen J. Statistical power analysis for the behavioral sciences. Hillsdale: L. Erlbaum Associates; 1988.

El Fassi M, Bocquet V, Majery N, Lair ML, Couffignal S, Mairiaux P. Work ability assessment in a worker population: comparison and determinants of Work Ability Index and Work Ability Score. BMC Public Health 2013; 13: 305.

Damschroder LJ, Aron DC, Keith RE, Kirsh SR, Alexander JA, Lowery JC. Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implement Sci 2009; 4: 50.

Schelvis RM, Oude Hengel KM, Burdorf A, Blatter BM, Strijk JE, van der Beek AJ. Evaluation of occupational health interventions using a randomized controlled trial: challenges and alternative research designs. Scand J Work Environ Health 2015; 41: 491–503.

Imbens GW. Nonparametric estimation of average treatment effects under exogeneity: a review. Rev Econ Stat 2004; 86: 4–29.

Additional Files



How to Cite

Markus, M., Euhus, A., & Bethge, M. (2022). Effectiveness of behavioural medical rehabilitation under real-life conditions in Germany: A propensity-score matched analysis. Journal of Rehabilitation Medicine, 54, jrm00248. https://doi.org/10.2340/jrm.v53.469



Original Report