Evaluation einer multimodalen Schmerztherapie am UniversitätsSchmerzCentrum Dresden

Background

Data of a multimodal pain management program of the multidisciplinary pain management centre at the University Hospital of Dresden is presented. Over a period of 4 weeks, supplemented by an additional week 3 months later (booster week), patients with chronic pain of different origins are being treated in groups of 12. Based on the principles of the biopsychosocial pain model and the idea of functional restoration, the program is dedicated for pain patients where outpatient treatment was insufficient.

Methods

The program was evaluated on the basis of pain intensity (NRS), pain disability (PDI), fear and depression (HADS-D), catastrophizing (CSQ) and health-related quality of life and vitality (SF-36). The data were collected at the beginning and end of the initial 4 week treatment period, at the end of the booster period as well as 6 and 12 months after the end of active treatment.

Results

A total of 189 patients were included in the program in the period from January 2006 until August 2008. All outcome parameter showed statistically significant improvements with small to high effect sizes (ES 0.20–0.95). The results stayed stable even 1 year after the treatment. The highest effect sizes were found in catastrophizing (ES 0.86) and average pain intensity (ES 0.95). The primary pain diagnosis (e. g. low back pain versus headache) had no impact on treatment outcome.

Conclusion

Significant and clinically relevant improvements could be achieved with the multimodal pain management program in groups of 12 patients. The results were stable over a time period of 1 year. Pain diagnosis had no impact on the outcome.     

Neuropathischer Schmerz im stationären Bereich

Background

Neuropathic pain is a common symptom of many diseases among in-patients in hospitals and neuropathic pain itself often requires hospitalisation. It was the aim of this study to examine epidemiological key data related to neuropathic pain among hospital in-patients.

Methods

The source of the data used was the ICD-10 coded main diagnoses with neuropathic pain of a complete data set of discharges obtained for every Austrian hospital for the year 2002.

Results

A total of 49,412 cases (614/100,000 inhabitants) with diagnoses always associated with neuropathic pain were recorded, representing 2.0% of all discharges from Austrian hospitals. Furthermore, there were as many as 353,893 cases with diagnoses which are possibly associated with neuropathic pain, like cancer, diabetes mellitus and stroke, representing 14.3% of all cases discharged from hospitals. Applying the proportion of those suffering from neuropathic pain among patients with these three diagnoses which is known from the literature would result in 5.8% of all hospital in-patients suffering from neuropathic pain.

Conclusion

These data represent a first step in the assessment of the epidemiology of neuropathic pain and show the high extent of neuropathic pain in the Austrian in-patient setting.     

Interdisziplinäres Schmerzassessment im stationären Setting

Background

Chronic pain is characterized by a complex interaction of somatic, mental and social factors. Assessing these factors in patients with chronic pain is vital during the diagnostic work-up and when making a structured treatment plan. Interdisciplinary pain assessment (ISA) is the most promising method to deal with these challenges. This article presents our experience in performing pain assessments in the hospital setting and also illustrates the characteristic features of chronic pain patients undergoing such assessments.

Methods

This study reviews and evaluates patient data from 2704 ISAs performed at the Interdisciplinary Pain Centre of the Zentralklinik Bad Berka, Germany, between 2008 and 2015.

Results

The majority of our ISA patients are severely handicapped and show distinct signs of chronic disease. A large proportion of patients is either unable to work or receiving benefits (invalidity pension or retirement pension). In addition, patients reported long disease durations and high emotional distress. Treatment recommendations were based on the patients’ individual clinical presentations and examination results. More than half of the patients required multimodal pain management, while adjustments or therapeutic withdrawal of pain medications, in particular of opioids, were indicated in many patients.

Discussion

Our study shows that ISA enables fast, high-quality diagnostic assessments of chronic pain while taking the biopsychosocial model of pain in particular into account. In addition, ISA is not biased with regard to outcome results and recommends the further treatment that appears best for the individual patient. ISA leads not only to inpatient treatment, but also to treatment in other therapeutic settings and, as such, is not merely a door-opener to multimodal pain therapy.

     

Umsetzung der interdisziplinären multimodalen Schmerztherapie nach OPS 8‑918

With the implementation of the German diagnosis-related groups (DRG) reimbursement system in hospitals, interdisciplinary multimodal pain therapy was incorporated into the associated catalogue of procedures (OPS 8?918). Yet, the presented criteria describing the procedure of interdisciplinary multimodal pain therapy are neither precise nor unambiguous. This has led to discrepancies in the interpretation regarding the handling of the procedure—making it difficult for medical services of health insurance companies to evaluate the accordance between the delivered therapy and the required criteria. Since the number of pain units has increased in recent years, the number of examinations by the medical service of health insurance companies has increased. This article, published by the ad hoc commission for interdisciplinary multimodal pain therapy of the German Pain Association, provides specific recommendations for correct implementation of interdisciplinary multimodal pain therapy in routine care. The aim is to achieve a maximum level of accordance between health care providers and the requirements of the medical examiners from health insurance companies. More extensive criteria regarding interdisciplinary multimodal pain treatment in an in-patient setting, especially for patients with chronic and complex pain, are obviously needed. Thus, the authors further discuss specific aspects towards further development of the OPS-code. However, the application of the OPS-code still leaves room regarding treatment intensity and process quality. Therefore, the delivery of pain management in sufficient quantity and quality still remains the responsibility of each health care provider.     

Aspekte einer liaisonpsychiatrischen Betreuung von Patienten einer universitären Schmerzambulanz

Background

Owing to a rise of psychosomatic comorbidities, the treatment of psychological disorders, which may negatively impact prognosis and therapy, is increasingly becoming a focus of attention for pain outpatient clinics.

Aim

This study investigates and discusses the advantages of liaison psychiatric care in a university pain clinic.

Methods

In this retrospective study, we investigated all patients who presented to an anaesthesiologically led pain clinic between January and June 2014. The psychiatric history was taken by the liaison psychiatrist of the pain clinic.

Results

In the period investigated, 485 patients were treated as outpatients. A psychiatric diagnosis was present 351 patients (72.4%). The distribution of the diagnoses was comparable with that of a consultation service. Adaptation and affective disorders dominated. The patients were preferentially treated with new generation antidepressants.

Conclusion

The constant presence of a liaison psychiatrist allows for timely, specialised care of pain patients in terms of a multimodal therapeutic approach.

     

Akutschmerztherapie in der stationären Versorgung an deutschen Krankenhäusern

Background

In 2007, the German national guidelines on “Treatment of acute perioperative and post-traumatic pain” were published. The aim of this study was to describe current structure and process data for acute pain management in German hospitals and to compare how the guidelines and other initiatives such as benchmarking or certification changed the healthcare landscape in the last decade.

Methods

All directors of German departments of anesthesiology according to the DGAI (“Deutschen Gesellschaft für Anästhesiologie und Intensivmedizin”, German Society for Anesthesiology and Intensive Care) were mailed a standardized questionnaire on structures and processes of acute pain management in their hospitals.

Results

A total of 403 completed questionnaires (46?%) could be evaluated. Of hospitals, 81?% had an acute pain service (ASD), whereby only 45?% met defined quality criteria. Written standards for acute pain management were available in 97?% of the hospitals on surgical wards and 51?% on nonsurgical wards. In 96?%, perioperative pain was regularly recorded (generally pain at rest and/or movement, pain-related functional impairment in 16?% only). Beside these routine measurements, only 38?% of hospitals monitored pain for effectiveness after acute medications. Often interdisciplinary working groups and/or pain managers are established for hospital-wide control. As specific therapy, the patient-controlled analgesia and epidural analgesia are largely prevalent (>?90?% of all hospitals). In the last decade, intravenous and oral opioid administration of opioids (including slow release preparations) has become established in acute pain management.

Conclusion

The survey was representative by evaluating 20?% of all German hospitals. The organizational requirements for appropriate pain management recommended by the German guidelines for acute pain recommended have been established in the hospital sector in recent years. However, the organizational enforcement for acute pain management in nonsurgical areas is not adequate yet, compared to the perioperative care. In all hospitals modern medication and invasive techniques are widely available.     

Versorgung von Diabetikern in station?ren Pflegeeinrichtungen des Kreises Heinsberg

Zusammenfassung Fragestellung: Über die Betreuung von Diabetikern in stationären Pflegeeinrichtungen gibt es bisher kaum Informationen. Ziel dieser Studie war daher, die diabetologische Betreuung dieser Patientengrupe mit Hilfe eines detaillierten Fragebogens zu dokumentieren. Patienten und Methodik: Dazu wurden im Kreis Heinsberg, Nordrhein-Westfalen, nach einvernehmlicher Beschlussfassung in der regionalen Gesundheitskonferenz alle 41 stationären Pflegeeinrichtungen angeschrieben und um Beantwortung spezifischer Fragen gebeten. 39 Heime, die 99,6% aller Heimbewohner im Kreis betreuten, nahmen an der Studie teil. Ergebnisse: Von den 1 936 Bewohnern hatten 507 einen bekannten Diabetes mellitus (Prävalenz: 26,2%), wobei der Anteil der Diabetiker mit steigendem Lebensalter abnahm, 37,0% der Patienten wurden mit Insulin behandelt, 46,7% nahmen orale Antidiabetika ein. Fortgeschrittene Spätkomplikationen waren dagegen nicht auffällig häufig (3,4% Amputationen, 13,6% Erblindungen, 1,0% dialysepflichtige Niereninsuffizienz). Bei der Mehrzahl der Diabetiker wurde der Stoffwechsel mittels Blutzuckermessungen überprüft, allerdings mit niedriger Frequenz bzw. nur sporadisch. Eine augenärztliche Untersuchung in den vorangegangenen zwölf Monaten hatte nur jeder zweite Diabetiker erhalten. Obwohl die hausärztliche Betreuung dieser Patientengruppe intensiv war (48,1% der Diabetiker mit mehr als zwei Arztkontakten/Monat, 48,7% mit ein bis zwei Arztkontakten/Monat), hatten 30,8% der Diabetiker in den letzten zwölf Monaten wenigstens einen Krankenhausaufenthalt. Bemerkenswert war außerdem, dass von den 834 Pflegekräften mit vollständigen Angaben lediglich vier eine spezielle diabetologische Zusatzqualifikation erworben hatten. Schlußfolgerung: Zusammenfassend legen die Ergebnisse dieser Studie nahe, dass die Betreuung von Diabetikern in stationären Pflegeeinrichtungen in einigen Aspekten nicht dem heutigen Kenntnisstand entspricht. Vordringliche Handlungsempfehlungen sind, die diabetologische Ausbildung der Pflegekräfte und die Kommunikation zwischen den Pflegeeinrichtungen und den Hausärzten zu verbessern. Abstract Background and Objective: Little information is available on the diabetes management of elderly people under institutional care. It was therefore aim of this study to assess the quality of diabetes care in this patient group. Patients and Methods: In the county of Heinsberg, North Rhine-Westphalia, after agreement in the local public health conference, all 41 nursing homes were addressed and asked to fill out a structured, detailed questionnaire. Thirty-nine institutions participated in the study representing 99.6% of all patients under such care. Results: Our of the 1936 residents 507 had known diabetes mellitus (prevalence 26.2%) with an age-dependent decrease. 37.0% of the diabetic subjects were treated with insulin, 46.7% received oral hypoglycemic agents. Advanced late complications were reported in a minority of patients (3.4% amputations, 13.6% blindness or severe visual impairment, 1.0% hemodialysis). In the majority of patients, the metabolic control was assessed by blood glucose measurement, but only in low frequency. Eye examination within the previous 12 months was reported for only 50.0% of the diabetic subjects. Although the diabetics were frequently seen by their doctors (48.1% > 2 consultations/month, 48.7% with 1 to 2 consultations/month), 30.8% had at least 1 hospital stay during the previous 12 months. Among the 834 nurses with the full dataset only 4 had a special training in diabetology. Conclusion: The results of this study indicate that the diabetes management of patients living in nursing homes only partially fulfills the current requirements for diabetes care. There appears to be a particular need to improve the nurses training in diabetes as well as the communication between nursing homes and doctors.     

Neuroanatomische Grundlagen des kraniomandibulären Systems

In the final habitual intercuspation the occlusion dominates the positioning of the temporomandibular joints (TMJ) and thus also motor function. If there is a discrepancy between the central physiological TMJ position and the mandibular joint position in habitual intercuspation with existing malocclusion, the consequence is a displacement of the TMJ from the physiological position. Incorrect loading of one or more teeth in malocclusion as well as incorrect loading of the TMJ, lead via proprioceptors, mechanoreceptors and nociceptors to stimulation in the trigeminal nerve with relaying via the caudal section of the spinal nucleus of the trigeminal nerve and the associated trigemino-cervical convergence. The interconnection in the wide dynamic range (WDR) neurons complex results in stimulation in the central nervous system. This information reaches among others the basal ganglia, which are directly involved in the planning of procedural learning and voluntary motor movement. The basal ganglia are involved in many processes, such as perception, learning, emotion, memory, attention and motor function. They select central signal input and output of both motor, cognitive and emotional nature.     

Schmerzchronifizierung bei Rückenschmerzpatienten in der stationären Rehabilitation

Background

Criterion-related validity of the Mainz Pain Staging System (MPSS) was examined.

Patients and methods

The effect of staging of pain on pain-related and psychosocial measures was investigated in a cross-sectional design among 478 patients with chronic low back pain in inpatient orthopedic rehabilitation (ICD-10 diagnoses: M45.4/M45.5, M54.4/M54.5). Pain-related measures were selected from the German Pain Questionnaire of the International Association for the Study of Pain (DGSS). The psychosocial measures depression (ADS), anxiety (HADS-D), somatization (SCL-90-R), quality of life (SF-12), functional capacity (FFbH-R), pain sensation (SES) as well as pain experience and strategies of coping with pain (FESV) were assessed. Furthermore, the frequency distribution of scores in the clinical range in pain-related and psychosocial measures depending on the staging of pain was examined. Finally, initial indications of the predictive validity of the MPSS were investigated among 116 inpatients.

Results

Staging of pain had a significant impact both on levels of measures and proportion of clinically referred patients. Patients in stage III, but also those in stage II showed significantly impaired levels. Patients in stage III also showed more scores in the clinical range than expected in the lowest pain intensity, ADS depression, somatization of the SCL, functional capacity, and pain sensation. The MPSS before rehabilitation, together with mental health, seem to be a good predictor of depressive symptoms 6 months after rehabilitation.

Conclusion

The results support criterion validity of the MPSS, however, they also corroborate the concept that identification of medium and high grade pain by the MPSS has to be followed by a psychological diagnostic assessment. By this stepwise diagnostic process, therapy aims and treatment regimens can be designed more adequately.