Abstracts Pädiater - Inhaltsverzeichnis

Abstracts

Abstracts P?diater - Inhaltsverzeichnis     

Risikoabschätzung in der Schmerztherapie

Analgesic therapy is not without risk. However, the risk of most analgesic interventions is minor compared to the risk of the inadequate treatment of pain and insufficient treatment may lead to chronic pain.A correct diagnosis should be the basis of any specific treatment of pain disorders. Only a diagnosis which implicates a multi-disciplinary assessment and which considers both the pathoanatomical, functional and biopsychosocial dysfunctions can lead to an adequate therapeutic intervention. Furthermore, therapeutic planning should include the personal needs of the patient and should have realistic aims.Pharmacological treatment is guided by the WHO pain ladder. The risks of the relevant substance groups must be considered. NSAIDs (non-steroidal anti-inflammatory drugs) which are included in all steps of the WHO pain ladder carry specific risks for the gastrointestinal, cardiovascular and renal systems and are contraindicated in many patients in need of analgesic therapy, e.g. in many elderly patients. Opioids which are recommended at steps 2 and 3 of the WHO pain ladder have less organ toxicity but they are still used reluctantly. Coanalgetics, especially antidepressants bear specific risks and the discussion on suicide rates under antidepressant medication is ongoing.Invasive methods such as the intrathecal application of analgesics are valuable procedures if the indication is correct and the treating physician has sufficient experience. Pain therapy is essential and the risks of the procedures are manageable. Considering the current knowledge on the mechanisms of pain sensitisation, the lack of adequate pain control can lead to chronic pain with severe consequences for the patient.     

Interventionelle Schmerztherapie an der Wirbelsäule

Interventional pain management techniques are important therapeutic modalities for treating pain coming from the musculoskeletal system, particularly the spine. At the latest, they are employed after failure of conservative treatment in the subacute/prechronic and chronic pain stage. Used for the correct indication, interventional pain management techniques are characterised by their quick and potent local pain relief and extremely low rate of adverse events. The positive short- and medium-term effect after a correctly performed intervention is well documented. The immediate pain reducing effect enables more effective implementation of necessary physio- or exercise therapy measures post intervention, due to the patient’s improved functional status. Interventional techniques are also used as a diagnostic tool and play a very important role in patients suffering from unclear treatment-refractory or chronic pain in particular, since spinal pain is frequently diagnosed as “chronic unspecific pain syndrome” far too early. Diagnostic blockade techniques are performed on nociceptors facet joints, sacroiliac joints, spinal nerves and discoligamentary structures. The diagnostic findings in chronic pain patients have to be discussed in a multidisciplinary team, to increase the surgical hit rate and to reduce the number of patients with “failed back surgery syndrome”. Due to the many different techniques as well as a sometimes nebulous and non-standardised indication spectrum, it is important to act under the provision of international guidelines.     

Muskuläre und arthromuskuläre Dysbalancen – Pro und Kontra

The often one-sided daily load and also lack of movement in certain sectors of the population can lead to muscular and arthromuscular imbalance. Many athletes are also forced by internationally laid down rules to carry out training under conditions of arthromuscular imbalance. This article demonstrates the effects of arthromuscular imbalance on the occurrence and development of sports-related injuries or false loading in various competitive sport disciplines. These should be taken into consideration when planning training.     

Primäre kapsuläre Steife der Schulter

Background

Primary capsular stiffness (PCS) is a common shoulder disease without identifiable etiology or associated pathology. The stage-adapted multimodal treatment of PCS is challenging and still requires optimization.

Objectives

The newest, evidence-based perceptions related to PCS with recommendation of clinically relevant diagnostic and therapeutic guidelines are summarized.

Materials and methods

Relevant, new findings regarding the etiology and diagnosis of PCS from the last 10 years were summarized. A 2012 treatment algorithm for PCS was updated and expanded with the most current knowledge.

Results

The subacromial space is involved in inflammatory processes in the initial phase of PCS. Identification of advanced glycation end products help with understanding the fibrotic changes. Elevated serum lipid levels are associated with PCS but their exact role remains unclear. Distension of the bursa in the superior subscapularis recess is a “new” suggestive MRI sign of the pathology. Combined intraarticular and subacromial corticosteroid injections seem favorable over intraarticular-only injections. Hospital-based exercise class is more effective regarding the functional outcomes of PCS than individual physiotherapy or home exercise. Additional passive stretching of the capsule in the pain-free frozen and thawing states is beneficial. After failure of nonoperative treatment of at least 6 months, arthroscopic arthrolysis is recommended.

Conclusions

Several publications in the literature over the past few years have contributed to an improved understanding and better treatment of PCS.

     

Dreiwöchige stationäre multimodale Schmerztherapie bei Kindern und Jugendlichen mit chronischen Schmerzen

OBJECTIVE: In children and adolescents we investigated the impact of a 3-week inpatient multimodal pain therapy on subjective burden of life, pain intensity, and number of days off from school 3, 6, or 12 months later. METHODS: At the beginning of therapy (inpatient setting) and 3, 6, and 12 months thereafter (outpatient setting) we collected the respective data using standardized questionnaires. For statistical analysis we used Wilcoxon's signed rank test. A p <0.05 was regarded as statistically significant. RESULTS: A total of 72 patients aged 7.5-18.2 years suffering daily pain entered the study, most of them being diagnosed with somatoform pain disease. After 3, 6, and 12 months, 65, 27, and 30 patients could be reevaluated. Mean pain intensity of the week before data acquisition was significantly less than at the beginning (2.9, 2.3, and 2.9 vs 6.3) as was the mean number of days off from school due to pain during the 4-week period before each day of data acquisition (1.8, 1.5, and 1.4 vs 9.2). Mean subjective burden of life was significantly less than at the beginning (24.5, 22.0, and 25.8 vs 37.8). CONCLUSION: Outpatient multimodal pain therapy has a sustained impact on children and adolescents suffering from chronic pain.     

Praktische Schmerztherapie in der pädiatrischen Onkologie

In pediatric oncology, optimal pain control is still a challenge. A structured pain history and the regular scoring of pain intensity using age-adapted measuring tools are hallmarks of optimal pain control. Psychological measures are as important as drug therapy in the prophylaxis or control of pain, especially when performing invasive procedures. Pain control is oriented toward the WHO multistep therapeutic schedule. On no account should the pediatric patient have to climb up the "analgesic ladder" - strong pain requires the primary use of strong opioids. Give opioids preferably by the oral route and by the clock - short-acting opioids should be used to treat breakthrough pain. Alternatives are i.v. infusion, patient-controlled analgesia, and transdermal applications. Constipation is the adverse effect most often seen with (oral) opioid therapy. Adverse effects should be anticipated, and prophylactic treatment should be given consistently. The assistance of pediatric nurses is of the utmost importance in pediatric pain control. Nurses deliver the basis for rational and effective pain control by scoring pain intensity and documenting drug administration as well as adverse effects. The nurses' task is also to prepare the patient for and monitor the patient during painful procedures. It is the responsibility of both nurse and doctor to guarantee emergency intervention during sedation whenever needed. In our guideline we comment on drug selection and dosage, pain measurement tools, and documentation tools for the purpose of pain control. Those tools may be easily integrated into daily routine.     

Schmerztherapie bei Kindern und Jugendlichen mit Hämophilie

Background

Children and adolescents with severe hemophilia commonly suffer from acute and chronic pain as a consequence of hemophilia-related bleeding. Intervention-related pain also plays a major role. Despite its high prevalence in this patient group, hemophilia-related pain is not always adequately addressed and sufficiently treated.

Objectives

This paper discusses how to improve pain management for children and adolescents (0–18 years) with hemophilia and which specific features in this population should influence decisions in pain management.

Materials and methods

An expert panel discussed challenges in pain treatment in children and adolescents with hemophilia. Recommendations are based on evidence and clinical experience.

Result

Pain management in children with hemophilia needs improvement. Children with hemophilia are at risk of developing chronic pain and of suffering traumatization due to insufficient pain management. Pain therapy can be challenging in these children as both their age and the underlying disease limit the options in particular in pain medication. The expert panel developed recommendations to improve pain management in children with hemophilia.

     

Botulinumtoxin A in der orthopädischen Schmerztherapie

Botulinum toxin A (BTX A) has been used for more than 20 years as a safe and effective treatment for numerous diseases characterized by pathological muscle hypertension. In patients suffering from dystonia or spasticity, it has been observed that use of BTX A results not only in muscle relaxation but also frequently relieves associated pain. This pain relief is often seen earlier and to a much greater extent than the muscular relaxation itself. This has led to extending the use of BTX A to treat various focal pain syndromes. The results of initial studies in specific musculoskeletal pain therapy suggest that BTX A infiltrations are effective in the treatment of chronic, therapy-resistant pain of the shoulder and back region. Furthermore, BTX A has been found to be a less invasive option for the treatment of chronic epicondylitis and similar tendonitis conditions. The healing process following rupture of tendons or muscle transfer operations may be improved. In adults with increased muscle tone and endoprostheses, the targeted relaxation of spastic muscles might increase the lifetime of the implant and diminish aseptic loosening. In children with cerebral palsy, prophylactic treatment of hip luxation appears possible. The doses used in pain therapy are low; if correctly applied, the tolerance and safety are high and the effect lasts for a number of weeks.     

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.     

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.

     

Die Qualität der postoperativen Schmerztherapie beeinflusst die Krankenhauswahl

AIM: The aim of the survey was to elucidate the significance of postoperative pain therapy for the patient and its influence on the choice of hospital. METHODS: This prospective, anonymous survey of consecutive patients in a general surgical clinic was performed by an independent study nurse. RESULTS: A total of 161 patients were included; 90% of the surgical patients considered "good pain therapy" as a highly important factor, and three of four patients would admit themselves more likely to a clinic well known for "good pain therapy." If the patients could choose their hospital, factors such as "medical care by the physicians" are most important (rank 1; rank 1 most important, rank 10 most unimportant) followed by quality of "nursing care" (mean rank 2.6) and "good pain therapy" (mean rank 3.6). Older patients (> or = 60 years) preferred a hospital with known "good pain therapy" more often for surgical therapy than younger patients (< 60 years). CONCLUSION: It can be concluded that postoperative pain relief is an important factor for the patients' selection of a clinic and is influenced by an age of > or = 60 years.     

Compliance-Probleme und verhaltensmedizinische Implikationen bei der medikamentösen Schmerztherapie

Ohne Zusammenfassung