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.     

Therapierefrakt?re ventrikul?re Tachykardien bei einer Patientin mit prim?rem kardialen Non-Hodgkin-Lymphom

Zusammenfassung Anamnese: Bei einer 65jährigen Patientin traten seit 1996 rezidivierend ventrikuläre Tachykardien auf. Untersuchungen: Elektrophysiologisch wurde ein arrhythmogenes Substrat im rechtsventrikulären Ausflußtrakt diagnostiziert. Im Kernspintomogramm wurde eine Infiltration der rechten Herzhöhlen konstant nachgewiesen. In der Myokardbiopsie konnte histologisch in einer kardiologischen Spezialklinik ein hochmalignes zentroblastisches Non-Hodgkin-Lymphom diagnostiziert werden. Die bei der körperlichen Untersuchung völlig unauffällige adipöse Patientin wurde in unsere Klinik zum weiteren Staging und zur Therapieplanung verlegt. Die Lactatdehydrogenase war stark auf 2030 U/l erhöht. Echokardiographisch erschien das Myokard des rechten Ventrikels verdickt und diffus verdichtet. Mittels Beckenkammbiopsie, Kernspin- bzw. Computertomographie von Thorax und Abdomen konnte ein systemischer Lymphombefall ausgeschlossen werden, so daß es sich um ein primäres kardiales Lymphom mit rezidivierenden ventrikulären Tachykardien handelte. Therapie und Verlauf: Durch kombinierte Radiochemotherapie konnte eine komplette Remission erreicht werden. Die Hochfrequenzablation sowie Amiodarontherapie blieben erfolglos. Obgleich kein vitales Lymphom mehr durch Kernspin nach erfolgter kombinierter Radiochemotherapie nachgewiesen werden konnte, kam es mehrfach zu spontanen symptomatischen Rezidiven der ventrikulären Tachykardien. Deshalb wurde (erstmals) bei einem Patienten mit primär kardialem Befall durch ein Lymphom ein Defibrillator (ICD) implantiert. Die Häufigkeit der ventrikulären Tachykardien nahm im weiteren Verlauf ab; bisher zeigte die Patientin keinen Rückfall des Non-Hodgkin-Lymphom (Nachbeobachtungsperiode 23 Monate). Abstract History: A 65-year-old woman had suffered from relapsing ventricular tachycardias (VT) since 1996. Findings: Physical examination was normal. An arrhythmogenic substrate was found in the right ventricular outflow tract by electophysiological examination. Nuclear magnetic resonance imaging (MRI) showed an infiltration of the right heart. Myocardial biopsy revealed a high-grade centroblastic non Hodgkin lymphoma. The patient was now transfered to our hospital for further treatment. Lactate dehydrogenase was elevated (2,030 U/l). Echocardiography showed a thickened and more reflecting right ventricular myocardium. Bone marrow aspiration and MRI/computed tomography of abdomen and thorax excluded a generalized stage. Ventricular tachycardias were caused by a primary cardiac lymphoma. Treatment and Course: Combined radio-chemotherapy succeeded in complete remission. High-frequency ablation and amiodarone failed. Although MRI showed no more vital lymphoma after the combined radio-chemotherapy the patient suffered from spontaneous and symptomatic relapses of VT. Therefore this patient with primary cardiac lymphoma was the first in literature to get a defibrillator (ICD). The incidence of VT decreased and up to now the patient showed no relapse of the non Hodgkin lymphoma (follow-up 23 months).     

Frühpostoperative Eröffnung einer linkspersistierenden oberen Hohlvene nach bidirektionaler cavopulmonaler Konnektion – Coilembolisation als Therapie der Wahl

Zusammenfassung Im Rahmen von Palliativoperationen kongenitaler Herzfehler mit Etablierung einer Fontanzirkulation ist die pr?operative Diagnostik der systemven?sen Anatomie von besonderer Bedeutung. Pr?existierende Varianten, wie die linkspersistierende obere Hohlvene, kommen bei kongenitalen Herzfehlern geh?uft vor und k?nnen postoperativ für Zyanose und Herzinsuffizienz verantwortlich werden. Wir beschreiben einen 6 Monate alten Patienten mit einem imbalancierten atrioventrikul?ren Septumdefekt, bei dem sich nach Anlage einer bidirektionalen cavopulmonalen Konnektion in der frühpostoperativen Phase eine ausgepr?gte Zyanose entwickelte. Als urs?chlich für eine ineffektive Lungenperfusion konnte die Wiederer?ffnung einer linkspersistierenden oberen Hohlvene mit Drainage in den Sinus coronarius diagnostiziert werden. Durch Coilembolisation mittels replazierbarer Metallspiralen konnte das Lumen der linken oberen Hohlvene effektiv verschlossen werden. Die Zyanose besserte sich unmittelbar. Eine Coilembolisation stellt eine effektive Alternative zu einem chirurgischen Reeingriff dar, insbesondere bei postoperativ h?modynamisch instabilen Patienten. Eingegangen: 11. November 1998, Akzeptiert: 15. Januar 1999     

Leitlinie zur Pr?vention und Früherkennung von Brust- und Eierstockkrebs bei Hochrisikopatientinnen, insbesondere bei Frauen aus HBOC (Hereditary Breast and Ovarian Cancer) Familien

The Austrian guideline for prevention and early detection of breast and ovarian cancer in high risk patients--particularly in women from hereditary breast and ovarian cancer families--were established with particular consideration of the most recent position paper of the European Society of Breast Cancer Specialists (EUSOMA) by the authors mentioned above. The guideline is aimed at facilitating and standardizing the care and early detection strategies in women with an elevated life time risk for breast and ovarian cancer.     

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.     

Veränderlicher Muskeltonus bei passiver Hüftbeugung und -streckung zur Frühdiagnostik von Bewegungsstörungen in Hüfte und Becken

Background

In the literature, problems of the lower back are widely documented. Numerous authors mention that muscle tone and proprioceptive regulation are important processes in the development of normal stance and optimal mobility in the pelvic region. An increase of muscle tone during passive motions is mostly observed subjectively during diagnostic work-up for functional disorders of soft tissues and joints. Such an evaluation gives unverified qualitative results. To obtain quantitatively measured results of resistance of passive joint motion, it is possible to evaluate the muscle tone. Muscle tone is not a precisely defined value, but changes of muscle tone influence the quality of the joints’ passive motion.

Methods

To determine the joint’s functional state, we measured the muscle resistance during passive motion with different angular velocities in the full range of motion (ROM). We used a computer-monitored isokinetic device (REV 9000 Technogym) that allows passive flexion-extension motion in the hip joints in ROM 100°. The quality of passive hip joint flexion-extension motions depends on the functional state of lumbosacral region. We investigated 38 top sportsmen with normal functional state of the lumbosacral region and different lower back disorders (asymmetric pelvis, spondylitis in the lumbar region, lumbar hyperlordosis). We analyzed the muscle resistance during passive ROM as a resistive torque exchange, which was expressed as the average work done during 15 passive flexion-extension cycles of the hip in a given ROM. Based on these results, we calculated ratio of average work per cycle between agonist and antagonist muscles.

Results

We compared these results to the evaluated functional state of the lumbar and pelvic regions. We found an association between agonist and antagonist muscle tone differences and the functional disorders of the lumbar and pelvic regions. This method could be used for early diagnosis of functional disorders in the lower back.     

Schmerzakzeptanz – Konzept und Überprüfung einer deutschen Fassung des Chronic Pain Acceptance Questionnaire

Background

Up to now, only an English version of the Chronic Pain Acceptance Questionnaire (CPAQ) has been available for measuring the acceptance of chronic pain. This paper presents and analyzes a German adaptation of this instrument.

Methods

The German scale was tested on 150 patients at the DRK Pain Center in Mainz. Validity was assessed by means of various indicators of pain and psychosocial impairment. In a subgroup (n=50) the association with the heat pain threshold was determined.

Results

The factor structure of the German CPAQ scale is largely concordant with the theoretical model. The internal consistency of the total and subscales is 0.84–0.87 (Cronbach’s alpha). The factors are closely related to indicators of psychosocial functioning. Associations with the affective dimension of pain are moderate and with the sensory dimension low. No association is found with heat pain thresholds (thermal sensory analyzer).

Conclusions

The German CPAQ scale is a useful German-language instrument for the measurement of acceptance and shows good psychometric properties. The study confirms that acceptance is not an expression of a physiologically based indolence.     

Theorien und Modelle der Chronifizierung: Auf dem Weg zu einer erweiterten Definition chronischer Rückenschmerzen

Chronic back pain is one of the most common and costly disorders. An overview shows that chronicity has various definitions, of which purely temporal ones predominate. Back pain is said to be "chronic" if it lasts for a variable number of weeks or months. Our attempt to refine such definitions is based on three previous works: Loeser's multidimensional pain model, the oncological TNM model and the International Classification of Functioning, Disability and Health of WHO (ICF). We suggest an unidirectional process of pain in the back to a complex pain syndrome including other types of pain, various bodily complaints and cognitive as well as emotional impairments, and propose an empirically testable research model.