Multimodale Schmerztherapie bei chronischen und chronifizierenden Rückenschmerzen

Objectives

In recent years, multimodal treatment programs for chronic lower back pain (LBP) have been successfully established, however, the availability of such programs is limited. The aim of this study was to determine the predictors of success in a multimodal pain treatment program.

Methods

The study included 408 patients with chronic lower back or neck pain, who were admitted to a multimodal treatment program over 3 weeks. The German pain questionnaire was used for initial evaluation. Pain intensity was measured via VAS at the beginning of treatment and 6 months after therapy. The items on the pain questionnaire were tested by studying variance and regression analyses for their ability to predict treatment outcome (change of pain intensity).

Results

The following items could predict treatment outcome: duration of current pain episode, application for pension, pain intensity and job satisfaction. Age, sex, pain location (neck pain versus LBP) and chronicity stage according to MPSS were not found to be significant predictors.

Conclusions

According to our data, patients suffering from LBP or neck pain for less than 3 years, regardless of the stage of chronicity, can be expected to have a good outcome (pain reduction) after admission to a multimodal treatment program. Job satisfaction is a further predictor of good outcome. Predictors for a bad treatment outcome are: pain intensity less than 30/100 (VAS), pain duration longer than 3 years, and application for pension.     

Nichtmanuelle Schmerztherapie der Lenden-Becken-Hüft-Region

The goal of manual medicine is to relieve patients of their pain. However, some types of pain cannot be treated by manual therapeutic methods. Therefore, the current article reviews non-manual forms of pain therapy and their mechanisms of action. A distinction must be made here between nociceptive and neuropathic pain. On the one hand, these treatment techniques are pharmacological approaches based on WHO recommendations and current treatment guidelines, while on the other, they represent invasive treatments such as, e.g., neuromodulation. For the benefit of all patients, this article aims to span the divide between the two different approaches to pain therapy.     

Schmerztherapie bei Früh- und Neugeborenen

Pain is a central topic on neonatal intensive care units (NICU). Acute as well as prolonged (continuous and chronic) pain frequently occurs. Due to a lack of validated physiological measurement instruments for pain (e.?g. saliva cortisol, skin conductance and heart rate variability) pain in neonatology can only be assessed by external observation through the bedside team with pain scores using a regular, standardized procedure. During this very vulnerable period pain and medications (analgesics/sedatives) can negatively influence the brain development of premature babies and neonates. Therefore, limitation of the number of pain stimuli and the medicinal guideline “as much as necessary but as little as possible” are eminently important. When dealing with prolonged (continuous and chronic) pain, further challenges are a reduction of analgesics and sedatives as well as avoidance of withdrawal symptoms.     

Soziale Erwünschtheit in der Schmerztherapie

Background

Research on the quality of pain management is often based on self-reported data pertaining to internal regulations provided by employees. However, data examining the correctness of the information given are rare. The project “Pain-Free Hospital” facilitated such an analysis and compared the answers provided by staff members with currently existing regulations.

Methods

In the course of the project (2004–2006) data on internal pain-related therapy plans, pain management-related regulations as well as the level of knowledge of 3421 nurses, 1757 physicians (825 conservative ward physicians, 728 surgeons and 526 anesthesiologists) from a total of 19 hospitals were collected and examined prior to and after the implementation of a specific training intervention. The congruence of the answers given was measured.

Results

After training 16 surgical wards (previously 12) and 13 conservative wards (previously 2) had standardized therapy plans. Regulations existed in 13 conservative (previously 12) and 16 surgical wards (previously 12). In those hospitals with standardized therapy plans, a significantly higher level of knowledge was found among staff members after the intervention (p?<?0.05), especially on surgical wards. In hospitals without therapy plans and regulations there were significantly more incongruent answers (p?<?0.05). In comparison to colleagues from conservative wards, surgical nurses and physicians provided significantly more incongruent answers.

Conclusion

Therapy plans and pain management-related regulations are known in hospitals after a systematic training. Data suggest that hospitals without regulations show a trend towards social desirability.     

Schmerztherapie – Freibrief für Scharlatane?

Ohne Zusammenfassung     

Multimodale Schmerztherapie für die Behandlung chronischer Schmerzsyndrome

Multimodal pain management is a comprehensive treatment of complex chronic pain syndromes. In addition to medical therapy various other specialized therapeutic interventions based on the biopsychosocial model of pain origin and chronic pain development, are added. During the last few years treatment centers for chronic pain have been established throughout Germany. Multimodal pain management has been included in the official catalogue of the recognized medical procedures for day clinic units as well as for inpatient pain management. In daily practice there is, however, still a lack of clarity and of consistency about the components that multimodal pain management should contain. This is the reason for the ad hoc commission on multimodal interdisciplinary pain management of the German Pain Society to propose the following position paper that has been worked out in a multilevel and interdisciplinary consensus process. The paper describes the mandatory treatment measures in the four core disciplines of multimodal pain management, pain medicine, psychotherapy, exercise therapy including physiotherapy and assistant medical professions including nurses.     

Schmerztherapie bei chronischer Pankreatitis und chronisch-entzündlichen Darmerkrankungen

Apart from local inflammation and defects in secretion, central mechanisms are important for pain etiology in chronic pancreatitis. Therefore, centrally acting co-analgetic agents can be used in addition to classical pain medications. Endoscopic interventions are preferred in patients with obvious dilation of the pancreatic duct. Surgical interventions are generally more effective although they are usually reserved for patients with prior failure of conservative treatment. Diverse surgical options with different efficacies and morbidities are used in individual patients. One of the main problems in chronic inflammatory bowel diseases is abdominal pain. Primarily the underlying disease needs to be adequately treated. Symptomatic pain management will most likely include treatment with acetaminophen and tramadol as well as occasionally principles of a multimodal pain regimen. For the treatment of arthralgia as well as enteropathy-associated arthritis the same treatment options are available as for other spondyloarthritic disorders.     

Rückenschmerz

Ohne Zusammenfassung

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Back painSo many questions and still far too few answers

     

Bedeutung des Bildungsniveaus für die Wirksamkeit der multimodalen Schmerztherapie

Background

The recommended treatment for chronic pain is multidisciplinary with a cognitive approach. The aim of this study was to investigate whether the education level of patients was predictive of main outcome dimensions (pain intensity, disability, depression, physical functioning and return to work).

Patients and methods

This was a secondary analysis of 413 patients who participated in an in-patient multidisciplinary pain treatment program. All patients were studied at baseline and after 6 months. The aim was to find predictors for the changes in scores of outcome measures (from admission to follow-up). Possible predictors were educational level and other available variables that are considered prognostic of treatment outcome, including age, gender, body mass index, endurance of pain, pain intensity, depressive symptoms and work status. Classification trees were used to predict outcome variables.

Results

The outcome was markedly improved in the sampling collective at follow-up compared with baseline. Education was the best predictor of treatment outcome and affected 4 out of the 5 outcome dimensions analyzed.

Conclusion

If education level proves to be an intervening variable in further research, education adjusted treatment programs should be developed and evaluated.     

Periphere Opioidrezeptoren und ihre Bedeutung für die postoperative Schmerztherapie

Animal experiments have unequivocally demonstrated peripheral antinociceptive effects of opioids in inflamed tissue. Exogenous mu-, delta- und kappa-agonists can produce such effects. Opioid receptors are present on peripheral terminals of primary afferent neurons and their endogenous ligands are produced and contained in resident immune cells within the inflamed tissue. These endogenous opioid peptides can apparently be released during stress and produce intrinsic antinociception. A small number of clinical studies has examined the peripheral analgesic effects of opioids. Their results are equivocal so far. In view of the predominant role of the inflammatory process in the manifestation of peripheral opioid effects, the postoperative situation seems to be particularly worthwhile to study.     

Chronischer Rückenschmerz

Background

The aim of the study was to replicate the different reaction groups: “Fröhlicher Durchhalter (FD)” who are characterised by a positive mood and endurance strategies, “Depressiver Durchhalter (DD)” with depressive mood and cognitions to hold on and “Depressiver Vermeider (DV)” who are depressed with social and physical avoidance strategies. The replication was conducted with more feasible methods than the Kiel Pain Inventory (KPI), which had been frequently used in former research. This might effectuate a superior intervention outcome.

Patients/methods

The sample (n=290) consisted of patients after their first nucleotomy at the beginning of the inpatient medical rehabilitation. Selection of the scales was based on cognitive-emotional and behavioural pain characteristics. Therefore 14 scales of generic standardised questionnaires were investigated

Results

The cluster analysis revealed two heterogeneous groups: the FD (n=203, 75.7%) and DV (n=65, 24.3%). MANOVA showed significant differences between both groups (Wilks’ lambda: F (14,253)=30.97; p<.001); especially the emotional pain characteristics were relevant.

Conclusion

The study contributes to the methodological stability of two postulated groups. Thus further research should foster the development of risk-based interventions to evaluate if these groups offer an appropriate differentiation in rehabilitation.     

P?diatrische Schmerztherapie

Background

In order to provide efficient pain treatment clinicians need to know the latest developments in pain management and to implement this knowledge into clinical practice. The knowledge of pediatric nursing staff with regards to pediatric pain management has not yet been investigated. In this study we therefore investigated nurses?? knowledge of pediatric pain management strategies.

Methods

Nursing staff knowledge was analyzed using the German version of the PNKAS-Sr2002. This questionnaire was distributed to 310?pediatric nurses and the response rate was 51.3% (n=159). Analyses of variance (ANOVA) were conducted to examine whether educational level and work experience had an influence on knowledge. Independent from work experience the educational level of nurses is important for their knowledge in pediatric pain management.

Results

On average nurses obtained a mean individual test score of 69.3%. Nurses with advanced qualification and nurses with 6?C10?years work experience obtained the highest scores.

Conclusion

Pediatric nurses must be trained more efficiently in pediatric pain management so that an adequate pain management is available for children and adolescents.     

?Rücken-Coach“

Question

Back pain is a challenge for case management but is a health insurance fund (HIF) that identifies high risk patients and includes them in a back pain assessment and a multimodal program cost-effective?

Methods

Case managers of a HIF contacted selected patients and requested information on pain and current perspectives. Patients in the intervention group were offered a multimodal assessment and, if applicable, a multimodal treatment program. Control group patients received verbal or written (back book) information. Cost data were evaluated with respect to the interview data 1 year prior and 1 year afterwards.

Findings

Of the 800 insured persons contacted 621 were nationwide, 88 were regional controls and 91 were intervention patients. Inability to work was still rising in all groups but less in the intervention group versus both control groups. Drugs, hospital as well as cure/adjuvant costs were less for intervention patients than in both control groups. The investment for the program was thus more than refinanced.

Interpretation

Case management was well accepted but the intervention was in need of training for case managers and the specific diagnostic and treatment option regionally.

Funding

The HIF was responsible for the study investment and project partners shared the training of the HIF regional case managers.     

Rückfußarthroskopie

Hindfoot arthroscopy is a minimally invasive surgical method for treatment of Haglund’s deformity and pathologies of the posterior ankle and subtalar joints. From June 2006 to December 2008 a total of 53 patients were treated with hindfoot arthroscopy of which 46 patients were available for follow-up. The AOFAS hindfoot score improved from an average of 60 points preoperatively (range 42–80 points) to 90 points (50–105) postoperatively (p <0.001). The postoperative Hannover score averaged 91 points (76–100 points). Pain on the visual analog scale (VAS) improved significantly from 7.3 (3–10) to 1.8 (0–5). In the following paper the indications and technique of hindfoot arthroscopy are described.     

Akupunktur bei Rückenschmerzen

BACKGROUND: Acupuncture is commonly used to treat back pain. A meta-analysis of clinical trials of acupuncture for this condition came to a positive conclusion whilst a qualitative review was negative. AIM: To compare our meta-analysis of trials of acupuncture for the treatment of back pain with a qualitative review and the most recent studies on the subject. METHODS: A systematic literature search was conducted to retrieve all randomised controlled trials of any form of acupuncture for any type of back pain in humans. The adequacy of the acupuncture was assessed by consulting six experienced acupuncturists. The main outcome measure for the meta-analysis was numbers of subjects who where improved at the end of treatment. These data are discussed in relation to the qualitative review and the most recent studies. RESULTS: Twelve studies were included of which nine presented data suitable for meta-analysis. The odds ratio of improvement with acupuncture compared with control intervention was 2.30 (95% confidence interval 1.28 to 4.13). For sham-controlled, evaluator-blinded studies, the odds ratio was 1.37 (95% confidence interval, 0.84-2.25). The results from the majority of the most recent studies also support the effectiveness of acupuncture in the treatment of back pain. CONCLUSIONS: Collectively, these data imply that acupuncture is superior to various control interventions, although there is insufficient evidence to state whether it is superior to placebo.