Die kraniomandibuläre Dysfunktion

Although structural lesions in cervical vertebrae whiplash trauma stages 0 and I (introduction of the Coblenz Consensus report) are lacking or only minimally detectable, a chronification of symptoms occurs in 10–20% of those affected despite multimodal therapy. In these cases the question arises whether one or more pathogenetic factors were initially undiagnosed and not considered later in the therapy. It is nowadays practically undisputed that movements of the jaws and vertebral column are governed by a centrally controlled coordination and that craniocervical dysfunction (CCD) leads by a reflex action to craniomandibular dysfunction (CMD) and vice versa. In this study it was investigated whether trauma of the cervical vertebrae can lead to CMD which in turn maintains the functional CCD and the total complaints symptomatic. For this study 187 patients with chronic complaints following cervical vertebrae trauma were investigated with respect to CMD. CMD was initially diagnosed in a general medical manner using simple functional tests, with and without mandibular load and subsequently electrophysiologically confirmed by a dental examination. CMD was confirmed in all cases in addition to a CCD. The results of this study show that patients with persistent complaints following cervical vertebrae whiplash trauma regularly have a CMD. Treatment success underlines that a chronification of the complaints symptomatic can be clearly explained even with an unconsidered mandibular pathology and even in patients where the medical history goes back 5 years or more.     

Kreislaufabhängige tubuläre Insuffizienz bei Kaninchen

Research in Experimental Medicine -     

Multidisziplinäre Behandlung chronischer Polyarthritis

INTRODUCTION: To date only few studies have been reported on the effect of multidisciplinary inpatient treatment on pain experience in patients with rheumatoid arthritis (RA). Aims of the present research were: to asses the development of different pain qualities at the beginning, at the end of treatment and at a follow-up three months later in a RA-patient sample as a whole, to determine statistically and clinically significant changes on individual base, and to study pain coping behaviors as predictive and pain-change associated variables. METHODS: Subjects were 66 patients with a diagnosis of RA. They were treated with non-steroidal antiphlogistic and disease modifying drugs as well as with physical therapy. Measurement instruments were the pain experience scale with 5 subtests, the four-dimensional questionnaire of pain behavior, the functional disability scale, and a joint-index. RESULTS: At follow-up the reduction was strongest in the quality of persistent pain experience (effect size d: 0.54). Among sensory components a marked reduction was found for the experience of thermal pain. A statistically and clinically reliable change was assessed in 18% of he RA-patients, further 26% indicated a statistical only change. 33% remained stable at a functional level of pain experience. 12% did not change a high level of pain, and 11% deteriorated. Change in the coping behaviors of avoidance and support were associated with success in pain reduction. CONCLUSION: In the assessment of patient improvement different qualities of pain experience should be taken into account. It was suggested that inpatient multidisciplinary treatment was beneficial with regard to pain reduction in nearly on half of the RA-patients. The coping behaviors of avoidance and social support deserve attention as pain change associated variables.     

Sekundäre Steife der Schulter

Background

In addition to idiopathic shoulder stiffness, secondary shoulder stiffness in particular is often associated with extra-articular subacromial adhesions between the rotator cuff and the surrounding anatomical structures.

Objective

The aim of this article is to present clinical results and complications as well as the surgical technique of extra-articular release in the context of secondary shoulder stiffness.

Material and Methods

Selective review of the literature and presentation of own clinical experience.

Results

Intra-articular and extra-articular release are related to a high patient satisfaction and an improved range of motion. Exact knowledge of the extra-articular anatomy is necessary to prevent iatrogenic lesions of vessels, nerves and the rotator cuff. Compared to patients with a primary stiff shoulder, patients suffering from posttraumatic stiff shoulder benefit more from arthroscopic interventions with intracapsular and extracapsular release.

Conclusion

Restrictions in range of motion of the shoulder can be related to extra-articular adhesions. These adhesions need to be specifically addressed during arthroscopic treatment of stiff shoulders.

     

Intramuskuläre Injektionen im Kindesalter

Zusammenfassung Intramuskuläre Injektionen gehören zur gängigen Praxis in der ambulanten und klinischen Versorgung im Kindesalter. Impfstoffe, Prämedikationen und auch Analgetika werden über diesen Weg verabreicht. Der Schmerz einer intramuskulären Injektion ist groß, die Risiken einer Komplikation sind vergleichsweise hoch, und die Pharmakokinetik und Pharmakodynamik unsicher. In vielen Fällen existieren gleichwertige Alternativen einer rektalen, oralen oder nasalen Medikamentenapplikation. Intramuskuläre Injektionen in der Prämedikation und Schmerztherapie sind—abgesehen von Notfällen—obsolet. Diese Forderung entspricht den Leitlinien der Weltgesundheitsorganisation (WHO) und der International Association for the Study of Pain (IASP).Eine Stellungnahme aus dem Arbeitskreis Schmerztherapie bei Kindern der Deutschen Gesellschaft zum Studium des Schmerzes (DGSS)     

Monoradikuläre,lumbosakrale Wurzelkompressionssyndrome in Längsschnitt

A total of 97 patients with an acute monoradicular lumbosacral compression syndrome and a herniated disc at the same level were reinvestigated an average of 25 months after the acute event. Assessment was based on CT investigation and "root score", which was compiled from reports of subjective complaints and neurological deficits. All patients had initially undergone conservative treatment as inpatients. At the time of reinvestigation CT examination of the herniated discs revealed that they were unchanged in 56.7%, some-what smaller in 34%, no longer visible in 4.1% and larger in 5.2%. Nevertheless, 53.6% of patients were free of complaints, while 23.7% had improved clinically by more then 75%. The remainder showed improvement by about 25-75%. In no patient was the score unchanged or worse. In 69% of the patients neurological deficits were no longer demonstrable, and the remaining patients were not aware of deficits or did not feel any impairment from deficits that were obvious on clinical example. In 22.7% impairment was caused solely by local radicular or pseudoradicular pain. From these results it can be concluded that herniation of the disc precipitates the acute event but is not the sole source of the pain. In the majority of cases, during the further course of the disease the herniated disc causes no pain. It appears, therefore, that the course of disease following a disc herniation can be influenced very favourably by non-operative treatment and that in more than 50% of cases the condition becomes clinically silent. It follows that in neuroradicular compression syndromes a neurological deficit associated with the acute event does not mean operative intervention is indicated.     

Intraartikuläre Hyaluronsäure nach Arthroskopie des Kniegelenks

Background

Knee joint lavage is used when conservative measures are insufficient and a joint prosthesis is not indicated. The negative effects of lavage fluids on chondrocytes and the fact that post-arthroscopy (p.a.) pain and joint dysfunction may be due to a lack of synovial fluid (SF) led to the development of a SF substitute based on hyaluronic acid (HA).

Patients and methods

Eighty patients with persistent knee osteoarthritis (OA) pain underwent lavage with débridement if indicated. One group received an instillation of HA p.a. (A+HA, n=40) while the other group did not (A, n=40).

Results

Post-surgery pain and joint dysfunction improved substantially and similarly in both groups. At 3 months p.a. CGI (clinical global impression), pain on walking and at night, and functional difficulties worsened in A, but remained stable in A+HA (Mann-Whitney: described superiority A+HA). At 1 year p.a., these parameters reached proven superiority in A+HA.

Conclusion

Joint lavage in knee OA improves pain and function but p.a. instillation of HA provided longer lasting carry-over effects.     

Interdisziplinäre Betrachtung eines manualtherapeutischen Patientengutes

Introduction

Since the middle of the twentieth century, correlations between the disciplines of orthodontics and orthopedics have been discussed. Nevertheless, interdisciplinary treatment is seldom.

Patients and methods

A total of 262 children with a mean age of 6.90±2.83 years and a functionally and radiologically proven asymmetry in the upper cervical spine, also evident on palpation, were examined by an orthodontist. A postural test proposed by Matthiass was used to verify the efficiency of the supporting muscles. The number of manual therapeutic interventions was retrospectively registered and possible correlations between orthodontic findings and muscle tone were evaluated.

Results

Within this sample 84.2% of the children revealed a sagittal dysgnathic relation: 43.8% of the children showed a class II.1, 9.6% a class II.2, and 30.8% a class III malocclusion. A statistically significant correlation was found between sagittal dysgnathic jaw relation and weakness of the supporting muscles. No correlation was detected between the number of manual therapeutic interventions and dysgnathic jaw relation and weak muscle tonicity.

Conclusion

Children with asymmetry in the upper cervical spine demonstrate a high prevalence of sagittal dysgnathic jaw relation. Based on the detected correlation between weakness of the supporting muscles and an orthodontic dysgnathic finding, the therapeutic approach to strengthen the muscle tonicity is of special interest. A pathological orthodontic finding and a weakness of the supporting muscles do not seem to influence the number of manual medical interventions needed to successfully harmonize the asymmetry of the upper cervical spine.     

Retinoblastom – eine interdisziplinäre Herausforderung

Ohne Zusammenfassung

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Interdisziplinäre Therapie bei chronischem Schmerz

The article describes the interdisciplinary treatment of chronic pain at the Center of Pain Studies (CPS). The CPS is an intergral part of the Rehabilitation Institute in Chicago. An essential part of the program is a 1-day outpatient evaluation in which members of all disciplines take part. A team conference determines the appropriateness of the pain program for each patient accepted for further care at the CPS. In 50% of the patients chronic pain is connected with work-related accidents. General aims of the treatment are to return to productive life, improve emplopyability, increase activity level, improve mobility, apply pain management techniques, and improve coping. The program is monitored by an evaluation/follow-up system. Success criteria of the 6-month follow-up for the years 1987-91, such as less daily downtime in 58-78% of the patients, more time out on weekends in 40-68%, return to work in 50-67% and reduced depression in 37-70%, give an impression of the effectiveness of the pain management program.     

Anforderungen an eine interdisziplinäre Schmerzvorlesung

ZusammenfassungHintergrund Schmerztherapie ist auch nach der Neufassung der Approbationsordnung kein curricular verankerter Lehrgegenstand im Medizinstudium in Deutschland.Methodik Zur Erfassung der Wünsche von Studierenden an eine fakultative Lehrveranstaltung in Schmerztherapie ist während 2 Semestern an der Medizinischen Fakultät der Universität Münster eine Befragung unter Studierenden durchgeführt worden, die freiwillig eine solche Lehrveranstaltung besuchen wollten.Ergebnisse Die Hauptinteressen richten sich auf die Vermittlung konkreter Schmerzsyndrome (Rücken-, Kopf-, Tumorschmerz), der Pharmakotherapie und der Struktur der schmerztherapeutischen Versorgung. Weibliche Studierende äußerten ein signifikant stärkeres Interesse an der Schmerztherapie für bestimmte Zielgruppen (Frauen, Kinder, alte Menschen, Menschen mit HIV-Infektion). Als wichtigste Bestandteile von Lehrveranstaltungen wurden Fallbeispiele und Patientenvorstellungen gewünscht.Schlussfolgerung Die Analyse der gegenwärtig vorgeschlagenen Curricula für eine universitäre Lehrveranstaltungen in Schmerztherapie ergibt, dass die Curricula der IASP und der EFIC zu umfangreich bzw. zu theoretisch orientiert sind. Das Curriculum der DGSS deckt sich weitgehend mit den Wünschen von Studierenden. Fakultative Lehrveranstaltungen zur Schmerztherapie sollten die ermittelten Wünsche der Studierenden in der Themenauswahl und in den didaktischen Methoden berücksichtigen.     

Singuläre Kranzarterie mit langem Hauptstamm

Zusammenfassung Koronaranomalien sind selten und in der Regel benigne. Es wird der Fall einer symptomatischen 53-j?hrigen Patientin mit einer singul?ren Kranzarterie und langem linken Hauptstamm vorgestellt, die mittels Mammaria-Bypass behandelt wurde. Eingegangen: 4. Oktober 1999 Akzeptiert: 15. Dezember 1999     

Niedergelassene Pädiater und tertiäre Versorgungsstrukturen der Schmerztherapie

Background

Despite the urgency of the problem of chronic pediatric pain and the importance of early interventions, many children experience intermittent episodes of pain over a long period of time. One aim of this study was to investigate the need of structured diagnostic tools and therapies of chronic pediatric pain in pediatric general practices. Another aim was to describe the aims, services and challenges of a network between pediatric practices and a tertiary pediatric pain centre, from the perspective of general pediatric practitioners.

Material and methods

A qualitative research design was selected and 20 general pediatric practitioners were interviewed using a semistructured interview guide. Interviews were analyzed by use of qualitative content analysis according to Mayring.

Results

Generally, the idea of a network between pediatric practices and the German Pediatric Pain Centre was rated positively by pediatric general practitioners. From the results of the analysis three categories were identified: (i) expectations from the network (ii) desire for cooperation in the network and (iii) recommendations for improved patient care.

Conclusion

A network with a centre for tertiary care was preferred by the general pediatric practitioners. To optimize the care of children with chronic pain further education for general pediatric practitioners as well as structured diagnostic tools and therapies of frequent pediatric chronic pain diseases are warranted.     

Dynamische intraligamentäre Stabilisation und vordere Kreuzbandnaht

Following a distortion trauma with a blow to the lateral side of the knee during tackling in soccer, a rupture of the anterior cruciate ligament, a tear of the posterior horn of the lateral meniscus and a depressed fracture of the lateral condyle of the femur were determined in a 23-year-old man. Arthroscopic meniscal repair using the all-inside technique and repair of the anterior cruciate ligament were carried out with dynamic intraligamentary stabilization. In the postoperative course a re-arthroscopy and removal of the screw system was necessary because of pain above the proximal tibia. Arthroscopy showed a completely healed meniscus and a stable and healed anterior cruciate ligament. After removal of the screws and sutures the patient was free of complaints.     

Komplementäre und alternative Verfahren beim Fibromyalgiesyndrom

INTRODUCTION: Interdisciplinary S3 level guidelines were devised in cooperation with 8 medical, 2 psychological and 2 patient support groups. Results were elaborated in a multilevel group process. METHODS: On the bases of the "Cochrane Library" (1993-2006), "Medline" (1980-2006), "PsychInfo" (2006) and "Scopus" (2006) controlled studies and meta-analyses of controlled studies were analyzed. RESULTS: Only few controlled studies were found supporting in part the effectiveness of CAM therapies in the treatment of fibromyalgia syndrome. Due to the lack of information on long term efficacy and cost-effectiveness, only limited recommendations for CAM therapies can be given. CONCLUSION: Within a multicomponent therapy setting, selective CAM therapies (acupuncture, vegetarian diet, homeopathy, Tai Chi, Qi Gong, music-oriented and body-oriented therapies) can be recommended for a limited period of time.     

Komplementäre und alternative Verfahren beim Fibromyalgiesyndrom

Background

The scheduled update to the German S3 guidelines on fibromyalgia syndrome (FMS) by the Association of the Scientific Medical Societies (“Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften”, AWMF; registration number 041/004) was planned starting in March 2011.

Materials and methods

The development of the guidelines was coordinated by the German Interdisciplinary Association for Pain Therapy (“Deutsche Interdisziplinären Vereinigung für Schmerztherapie”, DIVS), 9 scientific medical societies and 2 patient self-help organizations. Eight working groups with a total of 50 members were evenly balanced in terms of gender, medical field, potential conflicts of interest and hierarchical position in the medical and scientific fields. Literature searches were performed using the Medline, PsycInfo, Scopus and Cochrane Library databases (until December 2010). The grading of the strength of the evidence followed the scheme of the Oxford Centre for Evidence-Based Medicine. The recommendations were based on level of evidence, efficacy (meta-analysis of the outcomes pain, sleep, fatigue and health-related quality of life), acceptability (total dropout rate), risks (adverse events) and applicability of treatment modalities in the German health care system. The formulation and grading of recommendations was accomplished using a multi-step, formal consensus process. The guidelines were reviewed by the boards of the participating scientific medical societies.

Results and conclusion

Meditative movement therapies (qi gong, tai chi, yoga) are strongly recommended. Acupuncture can be considered. Mindfulness-based stress reduction as monotherapy and dance therapy as monotherapy are not recommended. Homeopathy is not recommended. In a minority vote, homeopathy was rated as “can be considered”. Nutritional supplements and reiki are not recommended. The English full-text version of this article is available at SpringerLink (under “Supplemental”).