Comparison of Italian- and German-speaking patients with chronic pain
functioning were similar to those of our study. The Ita-
lian group showed no improvements in pain, disability,
mental state, flexibility and strength after 3 months of
treatment, while the GSP reported highly significant
improvements in all measurements.
Consistent findings revealed 2 cross-sectional
studies: Italian patients with chronic low back pain
reported the highest levels of emotional impairment,
second-highest levels of social impairment, and third-
highest levels of physical impairment compared with
different culture groups (38). Migrants from different
countries, who lived in Switzerland for longer had
worse health than indigenous Swiss people of the
same age (36).
In our data, important improvements in various
health dimensions were observed at discharge after
intensive inpatient treatment of GSP and ISP. Im-
provements in ISP were lower and in some health
dimensions even negative (worsening). Most of the
short-term improvements were maintained up to mid-
term (6 or 12 months) in GSP. In contrast, ISP lost
almost all of these improvements. This loss might be
caused by some of the complex interactions mentioned
above. Chronic pain can be initiated and increased
by psychological distress caused by perceived discri-
mination (39). One possible interpretation is that the
special needs of patients with a migration background
may partially be met within an inpatient IPMP held in
their native tongue, but are not generally met at home
after discharge. At the end of the programme all pa-
tients receive individually tailored recommendations
for subsequent outpatient management irrespective of
the language.
The differences in outcome between GSP and ISP
in this study cannot be explained by differences in
the language-specific programmes, since all therapies
and therapist were the same for both groups. Diffe-
rences in effects cannot be attributed to therapeutic
characteristics or comprehensibility. Inequalities in
baseline characteristics, which were (Table I) or were
not assessed in the study, are superficial. In addition,
heterogeneities of characteristics within the fibromy-
algia syndrome and back pain may have an impact.
Knowing these factors, higher sample sizes would be
needed to adjust for them.
Reducing language barriers by administering the
treatment in Italian language seems not to be suf-
ficient, because the improvements observed in the
Italian group were smaller than those of the German
group. In addition to language barriers, cultural bar-
riers have been shown to have a negative impact on
the recovery process (35): “Cultural differences may
result in diverging and conflicting representations of
health, illness and therapy, and this may hinder the
133
healing process or even cause its failure”. Four medi-
ating factors in intercultural care have been identified
to facilitate or hinder the care relationship and, by that,
the rehabilitation process: (i) humanity in care, (ii)
communication, (iii) the role of the family, and (iv) the
hospital’s organizational culture (40). Adapting the th-
erapy content in combination with specific intercultural
competence training of all involved medical personal
might enhance the treatment effect in the IPMP by
implementing a comprehensive “cultural sensitive
care in which patients are cared for in a holistic and
dignity-enhancing way” (40).
For detailed insight into these complex clinical
situations, various factors should be further investi-
gated: (i) influence of migration details (e.g. migra-
tion background, migration trajectories), (ii) level of
acculturation (language skills among other factors),
(iii) identification of key aspects of intercultural com-
petence and communication in different care settings
and health professions, (iv) adaptation of methods
and content of treatments, (v) definition of health and
pain, particular needs and specific expectations from
a patient’s perspective, and (vi) choice of assessments
to measure change of main problems of these patients.
This study has several weaknesses. There was a lack
of detailed information about socioeconomic status and
migration information, including land of origin, place
of birth and reasons for migration. Socioeconomic
status was approximated by education and occupation
level. The high number of patients lost to follow-up is
a potential threat to the internal and external validity
of this study. However, sensitivity analysis showed
rare differences in baseline characteristics between
the subjects who completed the study and those who
dropped out during observation time. This means, that
selection bias due to sex, age and SF-36 baseline score
differences was small. A further weakness is the lack of
knowledge about the treatment during follow-up peri-
ods after discharge. Continuation of the recommended
therapies after dismissal was not assessed. Although
both versions of the SF-36 have been derived from
and validated to the English original, cross-validation
between the German and Italian version has not been
performed. Psychometric differences between the 2
versions may exist and contribute to the differences
of the outcome measurement.
A strength of this study is the naturalistic, pro-
spective study design with comparison of 2 groups
participating in the same IPMP with the same therapy
components in different languages. ISP received the
same therapies as the GSP in their own language. A
further strength is the consistency of the differences
across 2 different samples. Although the observational,
non-randomized study design without a control group
J Rehabil Med 51, 2019