Wissenschaftlich gestütztes Training für Krankenversicherte mit Rückenbeschwerden

ZusammenfassungHintergrund In der Rangliste an Krankheitskosten nehmen die Erkrankungen der Muskel-Skelett-Verletzungen den dritten Platz ein. Rückenschmerzen spielen dabei eine entscheidende Rolle. Der Sachverständigenrat fordert insbesondere die Kostenträger im Gesundheitswesen zu qualitätssichernder Kosten- und Nutzenevaluation und zum Case Management auf. In diesem Zusammenhang bietet die Gothaer private Krankenversicherung ihren Mitgliedern seit 2001 die Integrierte Funktionelle Rückenschmerztherapie nach FPZ-Methode zur aktiven Bewältigung ihrer Beschwerden an. Eine Kosten-Nutzen-Analyse sollte belegen, ob die hohen Leistungsaufwendungen für Rückenerkrankte durch diese Therapie gesenkt werden können.Methode Das Kriterium Wirbelsäulensyndrom mit erheblicher Symptomatik konnte bei 400 Versicherten aus dem Zeitraum 2001–2003 mit der in der Kooperationsvereinbarung festgelegten Rückendiagnose in der Leistungshistorie bestimmt werden. Davon absolvierten 94 die Eingangsanalyse, die 24 Trainingseinheiten und die Abschlussanalyse und bildeten die Experimentalgruppe. Von den Versicherten, die diese Trainingsmöglichkeit nicht wahrnahmen, konnten 205 Versicherte als Kontrollgruppe ohne Maßnahme herangezogen werden. Verschiedene Leistungsarten wurden unter den betriebswirtschaftlichen Kriterien nach dem Return of Investment (ROI) vergleichend geprüft.Ergebnisse Neben der medizinisch-therapeutischen Effektivität konnte die von der Gesundheitspolitik und dem Sachverständigenrat für die konzentrierte Aktion im Gesundheitswesen geforderte wirtschaftliche Effektivität signifikant belegt werden.     

Münzkopfschmerz

Background

Subcutaneous peripheral nerve field stimulation (sPNFS) is an established procedure for the treatment of chronic localized neuropathic pain of peripheral origin. The treatment of nummular headache primarily focuses on conservative methods with limited prospects of success. The role of sPNFS in the treatment of nummular headache has not been investigated as yet.

Question

Is the sPNFS an option in the management of nummular headache?

Materials and methods

In addition to a summary of established methods in the treatment of nummular headache, sPNFS as a possible form of therapy is discussed.

Results

A positive effect of sPNFS in terms of the treatment of nummular headache is shown.

Discussion

sPNFS stimulates free subcutaneous nerves and transmits a pleasant form of paraesthesia in the area of pain. If regular conservative therapy has already been exhausted, then sPNFS might be an effective new option in the treatment of nummular headache. sPNFS is a minimally invasive and low-risk procedure. However, the high treatment cost and restrictions regarding fitness to undergo MRI are points of criticism. Further studies are needed to define its potential and role in the treatment of nummular headache.

     

Rückenschmerz

Ohne Zusammenfassung

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Back painSo many questions and still far too few answers

     

Verbesserung der Compliance für Bewegungsübungen bei chronischen Rückenschmerzen mittels Handy-App

Manuelle Medizin - Kreuzschmerzen sind aufgrund der Häufigkeit in den Industriestaaten ein großes gesellschaftliches und ökonomisches Gesundheitsproblem. Als wichtigste Therapie zur...     

Die Muskulatur als Ursache für Rückenschmerzen

Zusammenfassung Die Funktion der Muskulatur scheint eine wichtige Rolle bei der Entstehung und Aufrechterhaltung chronischer Rückenschmerzen zu spielen. Eine muskuläre Insuffizienz, wie sie bei Rückenpatienten in vielen Untersuchungen nachgewiesen werden konnte, belastet die passiven, schmerzauslösenden Anteile der Wirbelsäule. Dabei spielt die funktionelle Instabilität der Wirbelsäule eine große Rolle. In den letzten Jahren konnten diese Veränderungen durch Oberflächen-EMG mittels Spektralanalyse, Untersuchung von Muskelfasertyp und -größe sowie durch Analyse der Körperkoordination nachgewiesen werden. Da viele Patienten mit chronischen Rückenschmerzen neben muskulärer Insuffizienz auch psychosoziale Probleme haben und ein ausgeprägtes Schon- und Vermeidungsverhalten zeigen, sind therapeutisch neben einem muskulären Training auch psychotherapeutische Maßnahmen notwendig.     

Natürlicher Verlauf bei Hüftdysplasie und Operationsergebnisse

Background

The prevalence of hip dysplasia in epidemiological studies ranges from 1–20%. The associated deformity is a risk factor for secondary osteoarthritis (OA) of the hip.

Objective

What is the natural course of hip dysplasia and is it influenced by cofactors? How successful are corrective surgical procedures?

Material and methods

Analysis of published investigations up to 2018 which provide data about the natural course of hip dysplasia and the results of the most important surgical treatment procedures.

Results

The vast majority of published studies confirm a correlation between hip dysplasia and OA. The risk of OA increases with reduced acetabular coverage and severity of instability (subluxation). Long-term survival and functional results after pelvic osteotomies are meanwhile very good, if the procedure is performed in young or middle-aged patients with good congruency of the joints and no relevant OA. Additional deformities (e.?g. cam deformity or femoral torsional malalignment) should be simultaneously addressed and the acetabular fragment needs optimal positioning. Only a few studies with small patient cohorts and short observation times are currently available on the isolated arthroscopic treatment of borderline dysplasia.

Discussion

The importance of hip dysplasia as an established risk factor for secondary OA and the good results of reorientation pelvic osteotomies justify surgical correction when considering the identified indication criteria. Due to a low but relevant potential for complications, surgery should currently not be recommended for asymptomatic patients in adulthood. Potentially relevant cofactors are important for estimation of the natural course as well as the indications for surgical correction.

     

Die Bedeutung entzündlicher Myopathien für die Praxis

Zusammenfassung Entzündliche Myopathien sind aufzugliedern in 2 Hauptgruppen: erregerbedingte (durch Bakterien, Viren, Parasiten, Protozoen) und immunogene Myositiden. Unter letzteren sind zu nennen: Dermatomyositis (DM), Myositiden im Rahmen immunogener Systemerkrankungen (sog. Overlapsyndrome), Einschlusskörpermyositis (IBM), und idiopathische Polymyositis (PM). Muskelschwäche und Atrophie sind führende Symptome aller immunogenen Myositiden.Als 3. Symptom finden sich Muskelschmerzen, besonders bei akuten Myositiden. Am Anfang der Diagnostik stehen die Elektronenmyographie sowie die gängigen Laboruntersuchungen. Myositisassoziierte Autoantikörper finden sich v. a. bei akuten Verlaufsformen. Kernspintomographie ist insbesondere bei (primär) chronischen Manifestationen indiziert. Goldstandard für die definitive Einordnung ist die Muskelbiopsie. Die Therapie der DM/PM besteht in Glukokortikoiden, meist in Kombination mit einem Immunsuppressivum. Intravenöse Immunglobuline sind bei der IBM die gegenwärtig einzig mögliche Therapieform.     

Versorgungsforschungsprojekt „Aktionsbündnis Schmerzfreie Stadt Münster“

Inadequate pain care in health care facilities is still a major concern. Due to structural and organizational shortcomings the potential of modern analgesia is far from being exhausted. The project "Action Alliance Pain-free City Münster" is designed to analyze the multiprofessional pain management in health care facilities in the model City of Münster in an epidemiologic study and aims to optimize pain management in accordance with nursing standards and medical guidelines. Hospitals, nursing homes, outpatient nursing services, hospices and pain care centers will be examined. After an analysis of the current state on the basis of a pre-test, the necessary optimization measures will be developed and implemented. Subsequently, the pain management will be reevaluated in a post-test. In partly still unexplored health care areas of Germany, epidemiologic data will be generated, barriers to the implementation of standards and guidelines revealed and measures of improvements developed and tested. In addition, interface problems between the evaluated sectors will be identified. In this article the objective and the methods of the project are described.     

Rückenmarknahe Schmerztherapie

Ohne Zusammenfassung     

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.     

Arthroskopische Hüftchirurgie

Zusammenfassung Psoasassoziierte Schmerzen und eine schmerzhaft springende Psoassehne werden konservativ behandelt. Bei persistierenden Schmerzen kann eine Tenotomie indiziert sein. Das arthroskopische Verfahren im Rahmen der Hüftarthroskopie des peripheren Kompartiments ermöglicht eine minimalinvasive, selektive Tenotomie der Psoassehne auf Gelenkniveau mit deutlich reduzierter Komplikationsrate. Im Gegensatz zum extraartikulären, endoskopischen Verfahren ist keine weitere Portalanlage notwendig, zudem können intraartikuläre Pathologien ausgeschossen oder direkt behandelt werden. Die arthroskopische Psoastenotomie bei 9 Patienten zeigte nach durchschnittlich 9 Monaten postoperativ gute Ergebnisse ohne Rezidiv, subjektive Beugeschwäche oder Komplikationen.Instabilität und primäre Kapsulitis sind wahrscheinlich seltene, aber zu beachtende Hüftpathologien. Sekundäre Bewegungseinschränkungen sind häufige Folgen chronischer Hüfterkrankungen. Zur arthroskopischen Kapselplikatur, Kapselshrinking und Kapselrelease mit oder ohne Narkosemobilisierung liegen bisher nur wenige Erfahrungen vor. Die ersten Ergebnisse erscheinen ähnlich vielversprechend wie am Schultergelenk. Kapsulotomie und Kapselresektion sind bereits feste Bestandteile der arthroskopischen Behandlung der sekundären Bewegungseinschränkung verschiedener Hüfterkrankungen.     

Chronischer Rückenschmerz

Background

The aim of the study was to replicate the different reaction groups: “Fröhlicher Durchhalter (FD)” who are characterised by a positive mood and endurance strategies, “Depressiver Durchhalter (DD)” with depressive mood and cognitions to hold on and “Depressiver Vermeider (DV)” who are depressed with social and physical avoidance strategies. The replication was conducted with more feasible methods than the Kiel Pain Inventory (KPI), which had been frequently used in former research. This might effectuate a superior intervention outcome.

Patients/methods

The sample (n=290) consisted of patients after their first nucleotomy at the beginning of the inpatient medical rehabilitation. Selection of the scales was based on cognitive-emotional and behavioural pain characteristics. Therefore 14 scales of generic standardised questionnaires were investigated

Results

The cluster analysis revealed two heterogeneous groups: the FD (n=203, 75.7%) and DV (n=65, 24.3%). MANOVA showed significant differences between both groups (Wilks’ lambda: F (14,253)=30.97; p<.001); especially the emotional pain characteristics were relevant.

Conclusion

The study contributes to the methodological stability of two postulated groups. Thus further research should foster the development of risk-based interventions to evaluate if these groups offer an appropriate differentiation in rehabilitation.     

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.     

Computergestützte Versorgungsforschung im Kompetenznetz ?Chronisch-entzündliche Darmerkrankungen“

Zusammenfassung Hintergrund:  Beratungsanl?sse aufgrund unterschiedlichster Darmerkrankungen und -symptome sind in der haus?rztlichen Sprechstunde h?ufig. Wenig ist allerdings über das tats?chliche Versorgungsgeschehen in der Hausarztpraxis bekannt. In der vorliegenden Untersuchung zeigen ?rzte mit Hilfe einer internetbasierten Dateneingabe das medizinische Betreuungsgeschehen gegenüber darmerkrankten Patienten in der haus?rztlichen Praxis auf. Mit der Nutzung des Internets werden neue Wege der Versorgungsforschung beschritten. Methodik:  Nach Programmierung eines digitalen Abfragesystems und dem Aufbau eines deutschlandweiten Verbundes von forschungsinteressierten Haus?rzten übermittelten ?rzte über 12 Monate mit Hilfe einer computergestützten Eingabemaske anonymisiert Versorgungsdaten von Patienten mit unterschiedlichen Darmbeschwerden und Darmerkrankungen via Internet an die Studienleitung. Ergebnisse:  94 Haus?rzte dokumentierten im Verlauf 1 Jahres 1 584 Patientenkontakte in der Datenmaske. Am h?ufigsten wurden die Beratungsanl?sse Bauchschmerz (39%) und ver?ndertes Stuhlverhalten (28%), jeweils > 21 Tage Dauer, nachgewiesen. Frauen klagten h?ufiger über Bauchschmerz als M?nner. Die Bereitschaft zur Kooperation mit Spezialisten (Ein- und überweisungen) war bei Symptomen im Darmbereich hoch, ohne dabei geschlechtsspezifische Unterschiede zu zeigen. Die computergestützte Dateneingabe der Studien?rzte erfolgte überwiegend au?erhalb der Sprechstundenzeiten, wobei meist mehrere Patienten w?hrend einer Eingabesitzung eingetragen wurden. Schlussfolgerung:  Der gro?e Anteil an Ein- und überweisungen zu Spezialisten deutet auf die hohe Betreuungsintensit?t von Patienten mit unspezifischen Darmbeschwerden hin. Computergestützte Eingabesysteme stellen eine aufwendige, aber umsetzbare M?glichkeit der Datenerhebung dar, die für zukünftige Projekte der Versorgungsforschung weiterentwickelt werden sollte.      

Akupunktur bei Rückenschmerzen

BACKGROUND: Acupuncture is commonly used to treat back pain. A meta-analysis of clinical trials of acupuncture for this condition came to a positive conclusion whilst a qualitative review was negative. AIM: To compare our meta-analysis of trials of acupuncture for the treatment of back pain with a qualitative review and the most recent studies on the subject. METHODS: A systematic literature search was conducted to retrieve all randomised controlled trials of any form of acupuncture for any type of back pain in humans. The adequacy of the acupuncture was assessed by consulting six experienced acupuncturists. The main outcome measure for the meta-analysis was numbers of subjects who where improved at the end of treatment. These data are discussed in relation to the qualitative review and the most recent studies. RESULTS: Twelve studies were included of which nine presented data suitable for meta-analysis. The odds ratio of improvement with acupuncture compared with control intervention was 2.30 (95% confidence interval 1.28 to 4.13). For sham-controlled, evaluator-blinded studies, the odds ratio was 1.37 (95% confidence interval, 0.84-2.25). The results from the majority of the most recent studies also support the effectiveness of acupuncture in the treatment of back pain. CONCLUSIONS: Collectively, these data imply that acupuncture is superior to various control interventions, although there is insufficient evidence to state whether it is superior to placebo.     

Diagnostik des Rückenschmerzes

Many different diagnostic procedures are used in patients with low back pain. Medical history and clinical examination, X-rays, computed tomography (CT)-scan, magnetic resonance imaging (MRI), diagnostic nerve root blocks and facet injections, functional tests in physiotherapy, strength tests of trunk muscles and work-related performance, and psychological and social evaluation including psychometric tests are only some of them. Despite this large number of procedures available, the scientific literature has not changed its conclusion that in about 80% of all back pain episodes the cause remains unknown. During the course of back pain episodes the relevant factors may change. The cause of the problem or the triggering factor of the pain episode may no longer be important during subacute stages, while others may be decisive for the transition to chronic stages. Thus, assessment of the cause is different from that of prognostic factors. There seems to be no consistent distribution of causes or ongoing factors in the population(s) of patients. While individual social factors may be the one important factor in one patient, functional and structural factors may be significant in another patient. Clinical examination is important, but several problems occur in the evaluation of patients with low back pain. Due to their anatomical location, important bony structures of the lumbar spine, e.g., disks or facet joints, are difficult to access by clinical examination. Additionally, there are only few diagnostic tests during clinical examination that do not rely on the patient's cooperation or communication. The term "unspecific back pain" for the majority of patients is scientifically sound, because it reflects the fact that the cause is unknown. It must be taken into consideration that this term enjoys only limited acceptance by both patients and physicians. Physicians are in charge of certifying work disability by assessing the interference of the patient's illness/disease with the specific requirements of his daily life or job. However, in clinical practice both the job tasks and the patient's abilities to perform these tasks with the given symptoms and signs is still difficult to evaluate and requires further definition.