Non-inferiority of hybrid outpatient telerehabilitation for patients with back pain: 3-month follow-up of a randomized controlled trial.

Participants and treatment staff were not blinded, and outcomes were self-reported. This can bias self-reported outcomes. Dropout was high, especially at 3 months, and was higher in the digital group. This raises the risk of attrition bias. Non-responders had higher sickness absence, lower pain self-efficacy, and lower education than responders. The paper reports that both groups were affected similarly. The digital back school was not tested alone. It was one part of a 3-week multimodal outpatient rehabilitation program, so the contribution of digital back school cannot be separated from the other treatments. The digital group had slightly lower treatment adherence. Evening online meetings may have been burdensome. Total treatment hours differed between groups: 69.9 hours in the digital group and 67.7 hours in the face-to-face group. Patients needed stable internet, a suitable electronic device, a camera, and German language skills. The findings do not apply to people excluded for those reasons. Counter-activities had significant differences in complete-case and per-protocol analyses. It was not a primary outcome. The study was conducted in German outpatient rehabilitation centers within a specific welfare system. Transfer to other settings is uncertain. No cost-effectiveness analysis was performed.

Funding came from the Federal German Pension Insurance, which reported that it had no impact on study design, data collection, analysis, interpretation, writing, or publication. One author was employed by GOREHA GmbH, the company that digitized the standardized back school and distributes the Caspar application used in the study. Another author is chief physician at an outpatient rehabilitation center and chairman of the Nanz Medico group, and all participants came from centers belonging to that group. Other named authors declared no competing interests.

Do not conclude that digital back school alone is better than face-to-face care. The primary outcome only showed that digital delivery was not worse, and the counter-activities benefit was a secondary finding seen only in complete-case and per-protocol analyses, not in intention-to-treat analyses. Both groups also received the same 3-week multimodal outpatient rehabilitation program.