Therapy goal setting in patients with psychological stress in orthopaedic and cardiac rehabilitation

OBJECTIVES: To study goal-setting for patients with psychological stress in orthopaedic and cardiac rehabilitation centres. DESIGN: A questionnaire assessing patients' somatic, functional and psychosocial status ("IRES"-questionnaire) was administered to 3109 patients with musculoskeletal diseases and 1670 patients with cardiovascular diseases from a total of 26 rehabilitation centres at their admission and discharge. For all patients, physicians filled in the "Physician's Sheet" ("Arztbogen") that assesses patient-specific goals of therapy. RESULTS: Nearly 50 % of the patients suffered from psychological stress at their admission. Of the patients with high psychological stress (higher than in 90 % of the general population) only 11.1 % (musculoskeletal diseases) and 3.4 % (cardiovascular diseases) were diagnosed as having a mental disorder (ICD-10 diagnosis in the range of F00 - F99). High psychological stress reported by patients themselves is associated with only a small increase of goal setting in psychological therapy documented in the "Physician's Sheet". The most important factors that influence the predefinition of psychological goals of therapy are high multimorbidity, an ICD-10 diagnosis in the range of F00 - F99, low age, high motivation for rehabilitation and being a woman. However, statistically significant differences between rehabilitation centres in the predefinition of psychological goals of therapy were detected. It can be assumed that differences in concepts of therapy are responsible for this finding. CONCLUSION: The results show that physicians use the patient's self-assessments of their psychological stress only to a small extent while planning psychosocial interventions and care. The predefinition of goals in a context of "forced" consideration of patients self-assessments leads to a higher degree of consistency between patients' judgements and goal settings. It also shows a slightly higher predictive power for rehabilitation effects than the predefinition of goals of therapy without noticing patients' self-assessments. This demonstrates the usefulness of a patient-centred screening instrument for psychological stress in orthopaedic and cardiac rehabilitation.     

Qualitätssicherung in der Therapie chronischen Schmerzes

Chronic pain is often associated with an array of general psychological dimensions such as depression, somatic symptoms, anxiety, anger and a loss of quality of life. Part VIII describes various instruments concerning each dimension and comments on their applicability within a diagnostic routine for chronic pain patients. TheAllgemeine Depressionsskala (German version of CES-D) is recommended for the assessment of depression, and theBeschwerden-Liste seems best for assessing somatic symptoms. Trait-anxiety and pain-unrelated state-anxiety seem not to be suitable because they lack significance for the therapy process. While the inventory for assessing anger still needs an empirical basis for chronic pain patients, quality of life inventories are not recommended for routine pain assessment.     

The importance of bodily complaints in patients with chronic back pain

Pain perception is a complex psychosomatic phenomenon and is influenced by different psychological variables. Apart from their pain perception, chronic pain patients also suffer from different bodily complaints. The clinical significance of this finding is not yet clear. Bodily complaints in chronic pain patients may represent (a) a bodily expression of depressive symptoms, (b) a sign of chronicity, and (c) the expression of a heightened bodily awareness in the sense of hypochondriasis. METHODS: A psychometric study was done with 83 patients with chronic low-back pain. The patients were interviewed and tested psychometrically. We administered a German scale to measure bodily complaints (BL), an inventory to measure the extent of depressive symptoms (DS) and two subscales of an personality inventory (bodily complaints and hypochondriasis). In addition, patients were evaluated according to three stages of chronification ("Mainz Pain Staging System"). Ten anamnestic variables from four dimensions (temporal aspects, spatial aspects, medication usage behavior and patient's health care history) are added to yield a total chronification stage with three stages ranging from acute to chronic pain. RESULTS: Results indicate that bodily complaints have to be interpreted as signs of depressive disorder and chronicity. Signs of bodily 'awareness' or 'somatic anxiety'- in the sense of hypochondriasis - could not be found. Hypochondriasis does not seem to play a significant role in chronification of low back pain. CONCLUSIONS: From a cognitive-behavioral perspective the results support the hypothesis that psychological disturbance in chronic pain is a cause of long-standing pain perception and the result of the chronification process.     

Mittelfristige Effekte einer multimodalen Behandlung bei Patienten mit Fibromyalgiesyndrom

Objective

Fibromyalgia shows a chronic course of the disease in most cases. Multimodal therapy has short-term effects but only intensive forms of therapy attain long-term effects. As part of an inpatient rehabilitation program a multimodal pain treatment including cognitive-behavioral therapy was conducted in order to evaluate medium-term effects.

Method

The German pain questionnaire (DSF), the hospital anxiety and depression scale (HADS-D), the chronic pain questionnaire (FESV), the short form questionnaire on indicators of rehabilitation status (IRES-24) and the self-efficacy scale (ASES-D) were distributed to 166?fibromyalgia patients (intervention group n=116; control group n=50) before and after rehabilitation as well as 6?months after treatment.

Results

The intervention group showed better results regarding symptoms (pain intensity, anxiety, depression), state of health (somatic health, psychological well-being, functioning in everyday life) and self-efficacy.

Conclusions

Based on the positive medium-term effects on functioning in everyday life and self-efficacy there is evidence that patients benefit from multimodal rehabilitation programs including integrative patient education.     

Zusammenhänge von Depressivität und Ängstlichkeit mit sozialer Erwünschtheit bei chronischen Schmerzpatienten

OBJECTIVE: This study examines the extent of self-reported pain and psychological distress in chronic pain patients and the influence of social desirability on the data collected. METHODS: In a cross-sectional multi-center study with 494 chronic pain patients, a pain questionnaire was used similar to the German Federal Health Survey of 1998. Depression and anxiety were measured with the German version of the Hospital Anxiety and Depression Scale (HADS-D) and social desirability with the German Marlowe-Crowne short scale for the measurement of social desirability (KS-SE). RESULTS: Chronic pain patients reported stronger and more frequent pain, as well as higher psychological distress than the general population of Germany. Of the patients, 36.4% showed depression (HADS-D/D >or =9) and 31.4% anxiety (HADS-D/A > or =11). Depressed/anxious patients stated pain intensities higher than non-depressed/non-anxious patients. In all, 48.4% of the patients achieved social desirability levels in the marked or moderate range. There were positive correlations for social desirability with self-reported pain and the use of therapy, as well as age. A negative correlation was found between anxiety and social desirability, while for depression this interaction appeared only after partial correlation analysis with control of pain and therapy variables. CONCLUSIONS: Both psychological distress and social desirability are common in chronic pain patients. Patients with high scores for social desirability reveal less depression and anxiety. The psychological distress caused by pain seems to be expressed by somatic complaints and therapy seeking. Since pain research is strongly dependent on the patient's self-report, social desirability should be considered as a factor which may impact measurements and decisions.     

Behavioral observation and analysis of pain behavior in critically burned patients

Although patients who have been critically burned obviously suffer significant levels of pain, they also appear to engage in adaptive behaviors with greater frequency than previously documented. Observers trained in the use of an objective, reliable coding system recorded 5 min samples of behavior during treatment procedures. Typically, patients report severe pain during procedures such as wound debridement, dressing changes, physical therapy, etc., and many dread having to undergo them. The coding system allowed for the concurrent recording of staff reactions to patients' pain behaviors, well-being behaviors (discussing progress, future plans, complying with therapeutic instructions, etc.), criticism and praise of the hospital and the staff, and focusing on other patient's problems.Results indicate that: (1) patients exhibit a significantly higher frequency of psychological and somatic well-being than psychological and somatic complaints, even in the context of an intense, typically painful, treatment procedure; (2) differences in the frequency of pain behaviors and of well-being behaviors were not systematically related to the expected burn-related variables, e.g., total body surface area burned, site of burn, days since onset; and (3) nursing staff who have not received specific training in the behavioral analysis and treatment of pain respond to most patient behaviors with positive reinforcement regardless of whether such reinforcement is therapeutically indicated. Behavioral implications for the theory and treatment of pain are discussed.     

Psychological and social complaints reported by Dutch patients to their family doctors

Ninety-three percent of all problems and complaints reported by patients aged 21 and older to their family physician dealt with somatic disorders, and only 7% with psychosocial problems. Psychological complaints were evenly distributed among major age groups, and between male and female patients. "Social problems" peaked in the middle-age range. The most frequently reported psychological problems were feeling anxious, nervous or tense; feeling irritable, angry, restless or agitated; experiencing feelings of depression; and disturbances of sleep. Marital problems, problems at work, and problems caring for an ill or disabled relative were the most frequently reported "social" reasons for encounter. More women than men reported feelings of depression and marital problems. Men more often felt irritable, angry, restless or agitated, and had more problems at work.     

Predictors of existential and religious well-being among cancer patients

Well-being and mental health are not only direct functions of amount of stress, but also depend on how people appraise and face critical situations. Spiritual well-being seems to be a central component of psychological health in physically healthy individuals and it offers some protection against end-of-life despair in those with chronic diseases. In this study, 250 out and in-patients with a cancer diagnosis were interviewed with standardised instruments to measure two aspects of spirituality, existential and religious well-being, coping strategies, psychological state, and quality of life (QoL). Using multivariate logistic regression models we found that coping strategies characterized by acceptance and positive reinterpretation of the stressor, and the absence of anxiety disorder, independently increased the likelihood of the existential well-being (Odds Ratio, OR, 7.7, and OR, 4.5, respectively), whereas religious well-being was not significantly associated with these variables. Our findings show that existential and religious well-being may be very different. A spirituality-based intervention could be differently utilized by patients with different beliefs, cognitive and behaviour characteristics. Measure of coping strategies and psychological state should be part of routine management of cancer patients.     

Differences in the psychological status of hysterectomy and non-hysterectomy women]

PURPOSE OF THE STUDY: Despite numerous investigations on the well-being of hysterectomized women, this issue is still discussed controversially. The aim of the present study was to reveal differences between a group of hysterectomized women with a fairly long follow-up period (7.9 years) and a group of non-hysterectomized women with respect to their psychological well-being. RESEARCH METHOD AND MATERIAL: In a questionnaire study we compared a group of 216 women who underwent hysterectomy with a group of 90 non-hysterectomized women. Dependent variables were: body complaints, psychological well-being, dysphoria, socio-sexual assertiveness, and gender-role orientation. RESULTS AND CONCLUSIONS: The group of hysterectomized women showed significantly higher levels of body complaints, depression, and unassertiveness in sexual situations, as well as decreased psychological well-being, and a more traditional gender-role orientation. Within the group of hysterectomized women, duration since hysterectomy, surgical techniques, and hormone substitution therapy seem to be unrelated to the psychological variables. The group differences cannot be causally attributed to the hysterectomy, since they may already have existed premorbidly. Nevertheless, the results suggest that a more thorough psychological examination prior to hysterectomy, as well as provision of support for the coping process after intervention is advantageous.     

Causal Thinking About Somatic Symptoms—How Is It Related to the Experience of Symptoms and Negative Affect?

The relation between causal thinking about somatic symptoms (psychological, somatic, and external symptom attribution) and the experience of somatic complaints and negative affect was studied in a community sample of 208 individuals. Although cluster analysis identified groups of individuals with psychological, somatic, and external attribution styles, the analysis also revealed groups of individuals with combinations of high or low scores on two or three attribution dimensions. Consistent with previous research, psychological attribution of symptoms was associated with a higher degree of somatic complaints and negative affect; this effect, however, was primarily due to a group of psychologizers/externalizers, and not to the pure psychologizers. Also in replication of earlier studies, all three attribution subscales were intercorrelated. The findings are discussed in terms of rumination processes. It is argued that the findings concerning psychological symptom attribution have received too little attention in the literature so far, probably because they go against dominant theoretical paradigms in psychosomatic medicine.     

Psychological well-being of spouses of stroke patients during the first year after stroke

OBJECTIVE: To investigate whether spouses' psychological well-being changed between the first weeks after their partner's stroke and four months and one year later, and to study the relationship between spouses' psychological well-being and objective characteristics of the stroke patients. DESIGN: Prospective, longitudinal study. SETTING: Hospital care and follow-ups. SUBJECTS: Sixty-seven consecutively enrolled spouses to first-ever stroke patients < 75 years. MAIN MEASURES: The Psychological General Well-Being (PGWB) Index. Clinical examination of the stroke patients. The Barthel Index. RESULTS: The spouses' psychological well-being was significantly lower in the first weeks after their partner's stroke as compared with norms. At four months, it had increased significantly. Between four months and one year, individual changes were observed in both positive and negative directions; thus, the mean level of the group remained constant. The spouses' psychological well-being in the first weeks was significantly related to the patients' sensorimotor impairments, while it was related at four months to cognitive impairment and the patients' abilities in self-care. At one year, psychological well-being was related to remaining sensorimotor and cognitive impairments. A significant relationship was also seen between the spouses' and the stroke patients' emotional health. CONCLUSIONS: The spouses' psychological well-being increased after the first chaotic weeks. The presence of visible impairments initially seemed to affect spouses' emotional health, while cognitive and emotional impairments became more evident in everyday life. In the long term, however, the spouses' individual life situations and coping abilities seem to be of relatively increasing importance for their continued well-being.     

Further development of peer-review-procedures in medical rehabilitation

In 2002, the peer review for the somatic indications of medical rehabilitation was further developed. This process was aimed at adjusting the peer review checklist to the "Guide for the Uniform Medical Report of the Statutory German Pension Insurance Scheme" ("Leitfaden zum einheitlichen Entlassungsbericht der Rentenversicherung"), at harmonising the peer review with the version used in the quality assurance programme of the German health insurance and at reducing requirements by focusing on criteria relevant in the individual case. This paper reports on the consensus process carried out and outlines the modifications of the peer review procedure.     

Recurrent Tension Headache in Adolescents Treated with Self-Help Relaxation Training and a Muscle Relaxant Drug

Forty-eight adolescents suffering from recurrent tension headache participated in a controlled trial conducted in a high school setting. During the first treatment phase self-help relaxation training was compared with a waiting-list group. Following this phase a pharmacological regimen consisting of a muscle relaxant (chlormezanone) and placebo was superimposed on relaxation therapy in a double-blind crossover design. Each treatment phase encompassed a 5-week period. In addition to the evaluation of headache complaints, psychological distress among students was measured with respect to their experience of somatic complaints, depressive, anxiety and stress symptoms. Although self-help relaxation training significantly decreased the severity and annoyance of adolescents' headache besides their somatic complaints, the clinical improvement of headache was modest. The addition of chlormezanone did not help those who were nonresponders to self-help relaxation training. Finally, a set of pretreatment variables consisting of baseline headache severity and annoyance, experience of anxiety and daily life stress among adolescents could predict outcome of self-help relaxation therapy.     

Chronifizierende Faktoren bei Patienten mit Schmerzen durch einen lumbalen Bandscheibenvorfall

Using a biopsychosocial model of chronic radicular pain, we conducted a prospective study on the predictability of the therapy outcome in 41 lumbar disc patients from the Department of Neurology, University of Kiel. Before therapy, all patients had an extensive neurological and psychological examination. The criteria for the therapy outcome werepersistent pain and theduration of hospital stay in days. As for the psychological predictors, we examined the amount of depression as a state variable (Beck Depression Inventory BDI), depression as a trait variable (Giessen test), several paincoping modes (Hoppe scale) and the general health locus of control. As somatic predictors, we assessed the duration of pain before treatment, the number of previous operations, motoric paresis and the patient's age. The results indicated that the BDI was the best predictor of persistent pain and of the duration of hospital stay as well. The sensitivity and specificity were more than 90%. Patients with a BDI score >9 remained 8 days longer in the hospital than patients with lower BDI scores. In contrast to this, depression as a personality dimension allowed no correct prediction of patients with persistent pain. Thus, only the situational aspect of a depressive state is a relevant risk factor for chronicity. Overt pain behavior, avoidance behavior and fatalistic control expectations are the best predictors of persistent pain besides the BDI. Patients with persistent pain when discharged from the hospital had significantly more overt pain behavior preoperatively than patients without pain. They admitted that they changed their posture more often; they groaned, grimaced, or rubbed the painful area more often. Thus, these data confirm the operant conditioning theory of Fordyce within a prospective design. Furthermore, patients with strong avoidance behavior in pain situations and with fatalistic health expectations remained 8 to 10 days longer in the hospital. Regarding the somatic factors, only paresis is a significant predictor of these criteria. Patients with clear paresis showed more pain and a longer duration of hospital stay. In general, there was no significant correlation between the organic and psychological predictors, so independent psychological screening and the prospect of psychological interventions are necessary measures to prevent persistent pain in lumbar disc patients.     

Findings on the effectiveness of rehabilitation

The German Federal Ministry of Education and Research (BMBF) and the German Pension Insurance scheme established a funding programme for research in rehabilitation. This review presents the findings of 38 available evaluation studies analyzing the effects of medical rehabilitation in Germany in different indications. With a total of 10 studies, the effectiveness of rehabilitation in chronic low back pain was evaluated most frequently. The other research projects analyzed the effects of rehabilitation in psychosomatic diseases (9 studies), cardiac diseases (9), cancer (4), neurological diseases (3), bowel diseases (1) and rehabilitation of children and juveniles (2). According to the results at hand, medical rehabilitation significantly improves the patients' state of health at the end of the rehab measure. Effectiveness is maintained in numerous patients also in the medium or fairly long-term. Hence, rehabilitation accomplishes a prerequisite for further gainful employment. Most of the patients treated have been suffering from chronic illness for many years and have developed psychological complaints besides their serious somatic symptoms and impairments. Here, rehabilitation takes on a fundamental assignment in the care of chronically ill patients. The projects carried out under the promotional focus highlight concrete perspectives for evidence based enhancement of medical rehabilitation. This, amongst others, also holds true for the positive experience with treatment modules within specific vocational training and with patient education. Some of the insights gained are already being realized. As a current task of development, the findings point to further improving the sustainability of rehabilitation's positive impact particularly in chronic low back pain. Pertinent conceptual approaches can be derived from the projects presented.     

Measuring disability of patients with low-back pain--validation of a German version of the Roland & Morris disability questionnaire

Introduction. In this study three instruments measuring disability of patients with low-back pain are presented and evaluated: (1) the Behinderungsfragebogen (RM) – a German version of the Roland &; Morris disability questionnaire (RDQ) (2) a numerical rating scale measuring disability in general and (2) eight numerical rating scales measuring specific dimensions of disability (standing, sitting, walking, driving a car, carrying light loads, carrying heavy loads, sleeping, and sexual intercourse). Methods. The psychometric evaluation, including the item analysis, test reliability, test validity, and responsiveness of the instruments, is based on two samples. Sample A comprises 345 patients with low-back pain: 282 of these patients took part in the Swiss multicentre intervention study testing the effectiveness of in-patient rehabilitation of sub-chronic and chronic low-back pain under an integrative group treatment program. The instruments were administered at different times in the therapeutic process (t1: at hospital admission; t4: follow-up after one year). 63 patients were hospitalized (orthopedic or rheumatological units) for medical examinations (myelography or infiltration of facets) or rehabilitation of low-back pain. The instruments were administered twice within 24 h to measure test-retest correlation. In order to determine the psychometric parameters as accurately as possible, the two samples were examined jointly. Sample B is composed of 41 patients with low-back pain participating in the study “Prädiktoren des Erfolgs bei stabilisierenden Wirbelsäuleneingriffen” (Success predictors of effectiveness of surgical interventions for spinal stabilization). Results. All instruments proved to be generally reliable and valid (high or medium correlations with each other and with a German version of the Oswestry Disability Questionnaire) as well as responsive tools for measuring the momentary disability of patients with back pain. The psychometric examination of the test validity showed that patients' perceptions of their disability were influenced by their psychological well-being. The correlation between the 3 instruments and physical tests was low. The RM is not a homogeneous instrument. Factor analysis (principal component analysis, rotation Varimax) indicated 6 factors. Because of the small number of items for each factor it is not appropriate to treat RM in terms of dimensions of disability. Conclusions. The RM is an instrument measuring patients' perception of their disability that offers simple, fast practicability for patients and tester. The 2 rating scales: The 8 numerical rating scales measuring specific dimensions of disability (QL3) offer all the advantages of the numerical rating scale measuring disability in general (QL1) (simple instruction, high plausibility for the patients, and simple, fast practicability), but they provide more information about the patient's disability, which allows comparisons of disability at different times in the therapeutic process. Numerical rating scales are not suitable for patients with poor ability to abstract. For these patients it is necessary to use a questionnaire which asks concretely about what the patient can or cannot do (e. g. RM). Because of its better psychometric properties, the QL3 should be favored over the RM.     

Hallucinogens,amphetamines and entactogens

MDMA ("Ecstasy") and its analogues such as MDE and MDA are amphetamine derivatives reported to produce an altered state with emotional overtones. Since more than ten years, ecstasy is after cannabis the most frequently used recreational drug by young adults, particularly in the so-called techno-scene. However, according to a recent survey there is an increasing trend for a revival of classic amphetamine and hallucinogen abuse, possibly due to the concern about the potential neurotoxicity and somatic risks associated with ecstasy use. Of the hallucinogens consumed, psilocybin containing mushroom ("magic mushrooms"), but also LSD are at the forefront. The present contribution summarizes the psychological and somatic effects of hallucinogens, amphetamines, and entactogens.