Europäische Pneumologie – Eine besondere Herausforderung für Deutschland und Österreich

Ohne Zusammenfassung     

Qualitätsindikatoren für die Versorgung von Patienten mit Rückenschmerzen

Introduction

Low back pain (LBP) is an epidemiologically and economically relevant health care problem appropriate for quality assurance approaches. Therefore an expert panel (AQUIK) of the National Association of Statutory Health Insurance Physicians has proposed three quality indicators (QI) for monitoring the quality of ambulatory care for LBP. The aim of this article is to present and evaluate the proposed QIs.

Material and methods

The three proposed QIs relating to red flags, imaging and sick leave certificates were evaluated with regard to the underpinning evidence, epidemiology and feasibility. Guidelines and original research as well results from surveys and observational studies evaluating adherence to LBP guidelines were used for assessment.

Results

The expert panel concluded that only the recording of red flags is a relevant and feasible QI. Despite a two-stage expert method the epidemiology of LBP, feasibility and existing routine health care data were not sufficiently taken into account. The author’s conclusion differs in two instances. The red flag concept is not sufficiently clinically validated and recordable to be used as a QI. Otherwise imaging is considered a suitable QI given the observed overuse and the availability of billing data.

Conclusion

Deriving valid and pragmatic QI from LBP guidelines for evaluating care for LBP is difficult. The core messages of guidelines are only recommendations with limited precision and transferability to individual patients. For pragmatic reasons definition of an upper or lower proportion of patients receiving a given health care service is recommended instead of tedious individual evaluation. Reasonable estimates can be based on data from research on health care services. Because of this uncertainty QIs should be evaluated before they are used as a steering instrument.     

Vergleich zweier Screening-Fragebogen für Patienten mit Rückenschmerzen

Background

Screening for risk factors for chronic low back pain (LBP) (yellow flags) is recommended by clinical guidelines. Various questionnaires to assess yellow flags have been proposed.

Objectives

The aim of this study was to compare the prognostic validity of two screening questionnaires.

Material and methods

This was a prospective observational study with 241 LBP patients from 9 general practitioners, 4 orthopedic surgeons and 2 pain clinics. We compared the Örebro musculoskeletal pain questionnaire (ÖMSPQ) and the Heidelberg short questionnaire (HKF-R10) which were completed by all patients at inclusion before the consultation. Primary outcomes were assessed after 3 months by mail. Clinical endpoints were pain intensity, disability and more than two follow-up consultations.

Results

The sensitivity of the HKF-R10 to predict the primary outcome ranged from 81 % to 88?%, while the specificity was much lower (37–47?%). The ÖMSPQ showed an opposite pattern with a low sensitivity ranging from 50 % to 58?% but a higher specificity (77–80?%). In patients initially classified as having chronic LBP (n?=?81), using the questionnaires as a diagnostic tool, the sensitivity of both questionnaires increased but specificity decreased. Single items may perform better with regard to primary outcome than the sum scores.

Conclusion

Both screening questionnaires for chronic LBP have insufficient diagnostic and prognostic validity for routine use in ambulatory care. Further studies are needed to improve diagnostic and prognostic validity and to elaborate criteria for a targeted use of screening questionnaires to guide therapeutic interventions.     

Bedeutung präoperativer Angst für den postoperativen Verlauf bei urologischen Patienten

Background

Preoperative anxiety is not systematically assessed during premedication appointments, although it may influence the postoperative course and outcome.

Objectives

The aim of this study was to assess preoperative anxiety in a sample of patients before major urological surgery and to characterize the impact on postoperative pain. An additional aim was to analyze the agreement between patients’ self-ratings and physicians’ anxiety ratings.

Patients and methods

In all, 127 male and 27 female patients participated in a prospective observational study. Preoperative anxiety was assessed with two validated instruments – the APAIS (Amsterdam Preoperative Anxiety and Information Scale) and the State Scale of the STOA questionnaire (State-Trait Operation Anxiety) – during the premedication appointment. Physicians provided their subjective ratings on patients’ anxiety and need for information using the APAIS. The predictive value of preoperative anxiety for postoperative pain was evaluated.

Results

Nearly four out of ten patients were identified as “anxiety cases”; thereof women were more afraid than men were. Preoperative anxiety was not correctly assessed by physicians, who overestimated patients’ anxiety. In female patients, preoperative anxiety was predictive of increased postoperative pain scores.

Conclusion

Preoperative anxiety is a frequent concern and often not correctly assessed by physicians. The use of scoring systems to detect preoperative anxiety is useful in clinical routine and helps to decide on therapeutic interventions.

     

Schmerzbewältigung für Rheumapatienten

Ohne Zusammenfassung     

Rücken stärken—Konzept und Evaluation einer Rückenschule für den Arbeitsplatz

Introduction

Our knowledge of the risk factors involved in the process by which acute pain becomes chronic has improved. Psychological conceptualizations of chronic pain presently include (1) the pain-tension cycle, with special reference to a diathesis-stress model, (2) the operant conditioning model, and (3) the interrelationship between vulnerability to pain attacks on the one hand and body posture, gait and activities of daily living on the other. With reference to these conceptualizations and to psychological procedures for the enhancement of self-management strategies, a low back school was implemented at the worksite as a preventive measure. The target population is characterized by (1) rare but recurrent pain episodes, (2) mild pain that has had little impact on daily activities, and (3) pain contingent on particular activities or situations.

Low back school

A low back school called “Turn your back on backache” consists of the following elements: (1) analysis of labour conditions and adaptation of the worksite to the person, (2) relaxation and stress management, (3) training of posture, gait, and activities of daily living, and (4) stretching and stengthening of the muscles involved. The programme comprises 12 2-h sessions and is conducted by a physiotherapist according to a manual, after an introduction to self-management procedures including behavioural training for working with groups. For homework, participants are asked to practise the exercises demonstrated.

Method and results

In a preventive context, pain ratings should be of minor importance as an outcome measure. Assuming that future pain is interrelated with present behaviour, changes in behaviour should be the predominant criteria applied to assess the effects of the training. Therefore, as well as assessments of pain episodes and wellbeing, a behavioural observation method based on video-taped behavioural assessment in a standardized situation was used. Course members had to demonstrate a sequence of different activities, including standing and walking, lifting and bending. Each sequence was rated on a four-point scale reflecting the degree to which adequate posture and gait were achieved. The final scale consists of 13 items with an inter-rater-reliability of 0.91 (Cronbach Alpha). The data for 283 persons attending in 31 courses in different industrial and administrative settings was used to evaluate the outcome. A marked decrease in pain episodes and an increase in health status and wellbeing were reported. Behaviour that was learned in the course had been incorporated into everyday activities at the worksite. The behavioural observation method was utilized in a subgroup of this sample who were on the staff of a university hospital. The study used a 2×2 repeated-measures design with the between-subject factor of treatment condition (training vs nontraining) and the within-subject factor of assessment period (pre-treatment=t1, post-treatment=12, 9-month follow-up=t3) allowing for analyses of variance (AN-OVA). Following a matched-pair design, for every person that participated in the training a control person was included in the study to allow control for gender, age, and occupation. This sample consists of 74 pairs and comprises nurses, administration personnel, physicians and physical therapists. Most (80%) are female. So far only 28 pairs have been reassessed at t3. A comparison of the overall scores obtained with the above items before and after treatment demonstrates an extremely significant interaction effect, indicating an increase of adequate behaviours in the treatment group. At the follow-up assessment, the observed effect was maintained.

Conclusions

(1) A back school training for the worksite results in a decreased frequency of back pain episodes and an increase in reported health status and wellbeing. (2) The effects of behavioural training of posture, gait, and activities of daily living in hospital staff are clearly demonstrated by observational methods. (3) Assuming that present posture, gait, and daily activities are interrelated with future pain conditions, an increase in the exercise of adequate behaviours indicates a preventive effect of the back school programme.     

Multimodale Komplexbehandlungen und Funktionstherapien für Kinder und Jugendliche mit Zerebralparese

Background and objective

Infantile cerebral palsy (ICP) is the most common cause of spastic syndromes in children and adolescents. It is caused by damage to the developing central nervous system. The structural damage is irreversible, but secondary functional disturbance of the loco motor system can be influenced by treatment. Since the functional problem is very often complex, different function-orientated multimodal treatment concepts (FMTC) have been developed for this patient group. In this review, the scientific evidence for these complex treatment programs is presented and discussed.

Methods

A literature search was conducted in the US National Library of Medicine, and a manual search in the Manuelle Medizin journal.

Results

A total of 57 relevant studies were found, of which 6 addressed FMTC. The other studies examined individual treatments frequently used in FMTC. Positive scientific evidence was found for all treatments. FMTC positively influenced patients’ motoric development.

Conclusion

FMTC and the functional treatments used in these programs positively influence development of the locomotor system in children and adolescents with ICP. Further studies are needed to assess the long-term sustainability of these effects.

     

Sport als Schädigungsfaktor für die Wirbelsäule

Background

Sports is often considered to be a possible trigger for spinal complaints, particularly by those who practice little sport themselves.

Objective

Review and presentation of literature results on sport as a triggering factor for complaints and diseases of the spine.

Materials and methods

A search was performed for articles dealing with different sports and their load on the spine, and complaints possibly resulting from overuse and overloading, such as low back pain. The results are presented in terms of the different sports and in terms of spinal injuries/diseases.

Results

Articles dealing with beach volleyball, cycling, tennis, golf, skiing, climbing, and weightlifting could be found from German-speaking regions. Especially among elite athletes, a high prevalence of spinal diseases, e.g. disc degeneration and spondylolysis, is presented. No significant correlation between imaging abnormalities and the complaints experienced by the athletes could be found.

Conclusions

In general, sports activity can induce degeneration and structural abnormalities in the spine in relation to duration, intensity and type of sports. But a low amount of physical activity may also provide complaints in the spine.

     

Deutsche Gesellschaft für Kardiologie – Herz und Kreislaufforschung

MITTEILUNGEN

Deutsche Gesellschaft für Kardiologie – Herz und Kreislaufforschung