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1.
Javier Pérez de Frutos Erlend F. Hofstad Ole Vegard Solberg Geir Arne Tangen Frank Lindseth Thomas Langø Ole Jakob Elle Ronald Mårvik 《International journal of computer assisted radiology and surgery》2018,13(12):1927-1936
Purpose
Test the feasibility of the novel Single Landmark image-to-patient registration method for use in the operating room for future clinical trials. The algorithm is implemented in the open-source platform CustusX, a computer-aided intervention research platform dedicated to intraoperative navigation and ultrasound, with an interface for laparoscopic ultrasound probes.Methods
The Single Landmark method is compared to fiducial landmark on an IOUSFAN (Kyoto Kagaku Co., Ltd., Japan) soft tissue abdominal phantom and T2 magnetic resonance scans of it.Results
The experiments show that the accuracy of the Single Landmark registration is good close to the registered point, increasing with the distance from this point (12.4 mm error at 60 mm away from the registered point). In this point, the registration accuracy is mainly dominated by the accuracy of the user when clicking on the ultrasound image. In the presented set-up, the time required to perform the Single Landmark registration is 40% less than for the FLRM.Conclusion
The Single Landmark registration is suitable for being integrated in a laparoscopic workflow. The statistical analysis shows robustness against translational displacements of the patient and improvements in terms of time. The proposed method allows the clinician to accurately register lesions intraoperatively by clicking on these in the ultrasound image provided by the ultrasound transducer. The Single Landmark registration method can be further combined with other more accurate registration approaches improving the registration at relevant points defined by the clinicians.2.
Hanne Sorger Erlend Fagertun Hofstad Tore Amundsen Thomas Langø Håkon Olav Leira 《International journal of computer assisted radiology and surgery》2016,11(8):1431-1443
Purpose
Endobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA) of mediastinal lymph nodes is essential for lung cancer staging and distinction between curative and palliative treatment. Precise sampling is crucial. Navigation and multimodal imaging may improve the efficiency of EBUS-TBNA. We demonstrate a novel EBUS-TBNA navigation system in a dedicated airway phantom.Methods
Using a convex probe EBUS bronchoscope (CP-EBUS) with an integrated sensor for electromagnetic (EM) position tracking, we performed navigated CP-EBUS in a phantom. Preoperative computed tomography (CT) and real-time ultrasound (US) images were integrated into a navigation platform for EM navigated bronchoscopy. The coordinates of targets in CT and US volumes were registered in the navigation system, and the position deviation was calculated.Results
The system visualized all tumor models and displayed their fused CT and US images in correct positions in the navigation system. Navigating the EBUS bronchoscope was fast and easy. Mean error observed between US and CT positions for 11 target lesions (37 measurements) was \(2.8\pm 1.0\) mm, maximum error was 5.9 mm.Conclusion
The feasibility of our novel navigated CP-EBUS system was successfully demonstrated. An EBUS navigation system is needed to meet future requirements of precise mediastinal lymph node mapping, and provides new opportunities for procedure documentation in EBUS-TBNA.3.
Bin He Chao Xu Yingdelong Mao Jingwen Mao Liping Shen Hao Wei Fei Wang Shuogui Xu 《International journal of computer assisted radiology and surgery》2016,11(11):2105-2110
Purpose
Metallic foreign bodies (MFBs) retained in soft tissue may pose potential threats to patient health. Interventional procedures using conventional navigation systems are associated with high rate of radiation exposure. We postulated that the surgical approach visualization and navigation system would offer precise percutaneous localization and linear guidance with reduced radiation dosage and system complexity.Methods
In total, 76 patients underwent percutaneous MFB extraction with the technique, which consists of: (A) displaying the target spot (here the MFB) on the screen; (B) projecting the laser beam onto the skin surface; (C) indicating the optimal direction and angle of the needle; and (D) guiding the surgical approach until the MFB was extracted.Results
A total of 76 MFBs were successfully extracted with a single operation. No systemic complications were observed. The procedure took between 2 and 11 min, with an average of \(5.55\pm 2.21\) min, demonstrating the characteristics of a normal distribution. The mean size of wound was \(12.01\pm 4.16\) mm. The mean amount of bleeding was \(6.12\pm 3.56\) ml. The number of times the intra-operative fluoroscopy was used ranged from one to four times for a single procedure, with an average of 1.89 ± 0.74.Conclusion
The proposed navigation system which combines the laser positioning and navigation techniques seems to be a novel surgical approach of high accuracy and efficiency.4.
M. A. Tavallaei M. K. Lavdas D. Gelman M. Drangova 《International journal of computer assisted radiology and surgery》2016,11(8):1537-1545
Purpose
To facilitate MRI-guided catheterization procedures, we present an MRI-compatible remote catheter navigation system that allows remote navigation of steerable catheters with 3 degrees of freedom.Methods
The system consists of a user interface (master), a robot (slave), and an ultrasonic motor control servomechanism. The interventionalist applies conventional motions (axial, radial and plunger manipulations) on an input catheter in the master unit; this user input is measured and used by the servomechanism to control a compact catheter manipulating robot, such that it replicates the interventionalist’s input motion on the patient catheter. The performance of the system was evaluated in terms of MRI compatibility (SNR and artifact), feasibility of remote navigation under real-time MRI guidance, and motion replication accuracy.Results
Real-time MRI experiments demonstrated that catheter was successfully navigated remotely to desired target references in all 3 degrees of freedom. The system had an absolute value error of \({<}\)1 mm in axial catheter motion replication over 30 mm of travel and \(3^{\circ } \pm 2^{\circ }\) for radial catheter motion replication over \(180^{\circ }\). The worst case SNR drop was observed to be \({<}\)3 %; the robot did not introduce any artifacts in the MR images.Conclusion
An MRI-compatible compact remote catheter navigation system has been developed that allows remote navigation of steerable catheters with 3 degrees of freedom. The proposed system allows for safe and accurate remote catheter navigation, within conventional closed-bore scanners, without degrading MR image quality.5.
Longfei Ma Zhe Zhao Fang Chen Boyu Zhang Ligong Fu Hongen Liao 《International journal of computer assisted radiology and surgery》2017,12(12):2205-2215
Purpose
We present a novel augmented reality (AR) surgical navigation system based on ultrasound-assisted registration for pedicle screw placement. This system provides the clinically desired targeting accuracy and reduces radiation exposure.Methods
Ultrasound (US) is used to perform registration between preoperative computed tomography (CT) images and patient, and the registration is performed by least-squares fitting of these two three-dimensional (3D) point sets of anatomical landmarks taken from US and CT images. An integral videography overlay device is calibrated to accurately display naked-eye 3D images for surgical navigation. We use a 3.0-mm Kirschner wire (K-wire) instead of a pedicle screw in this study, and the K-wire is calibrated to obtain its orientation and tip location. Based on the above registration and calibration, naked-eye 3D images of the planning path and the spine are superimposed onto patient in situ using our AR navigation system. Simultaneously, a 3D image of the K-wire is overlaid accurately on the real one to guide the insertion procedure. The targeting accuracy is evaluated postoperatively by performing a CT scan.Results
An agar phantom experiment was performed. Eight K-wires were inserted successfully after US-assisted registration, and the mean targeting error and angle error were 3.35 mm and \(2.74{^{\circ }}\), respectively. Furthermore, an additional sheep cadaver experiment was performed. Four K-wires were inserted successfully. The mean targeting error was 3.79 mm and the mean angle error was \(4.51{^{\circ }}\), and US-assisted registration yielded better targeting results than skin markers-based registration (targeting errors: 2.41 vs. 5.18 mm, angle errors: \(3.13{^{\circ }}\) vs. \(5.89{^{\circ }})\).Conclusion
Experimental outcomes demonstrate that the proposed navigation system has acceptable targeting accuracy. In particular, the proposed navigation method reduces repeated radiation exposure to the patient and surgeons. Therefore, it has promising prospects for clinical use.6.
Shuang Song Changchun Zhang Li Liu Max Q.-H. Meng 《International journal of computer assisted radiology and surgery》2018,13(2):241-251
Purpose
Flexible surgical robot can work in confined and complex environments, which makes it a good option for minimally invasive surgery. In order to utilize flexible manipulators in complicated and constrained surgical environments, it is of great significance to monitor the position and shape of the curvilinear manipulator in real time during the procedures. In this paper, we propose a magnetic tracking-based planar shape sensing and navigation system for flexible surgical robots in the transoral surgery. The system can provide the real-time tip position and shape information of the robot during the operation.Methods
We use wire-driven flexible robot to serve as the manipulator. It has three degrees of freedom. A permanent magnet is mounted at the distal end of the robot. Its magnetic field can be sensed with a magnetic sensor array. Therefore, position and orientation of the tip can be estimated utilizing a tracking method. A shape sensing algorithm is then carried out to estimate the real-time shape based on the tip pose. With the tip pose and shape display in the 3D reconstructed CT model, navigation can be achieved.Results
Using the proposed system, we carried out planar navigation experiments on a skull phantom to touch three different target positions under the navigation of the skull display interface. During the experiments, the real-time shape has been well monitored and distance errors between the robot tip and the targets in the skull have been recorded. The mean navigation error is \(2.07\pm 0.71\) mm, while the maximum error is 3.2 mm.Conclusion
The proposed method provides the advantages that no sensors are needed to mount on the robot and no line-of-sight problem. Experimental results verified the feasibility of the proposed method.7.
Objective
To compare the safety and estimate the response profile of olanzapine, a second-generation antipsychotic, to haloperidol in the treatment of delirium in the critical care setting.Design
Prospective randomized trialSetting
Tertiary care university affiliated critical care unit.Patients
All admissions to a medical and surgical intensive care unit with a diagnosis of delirium.Interventions
Patients were randomized to receive either enteral olanzapine or haloperidol.Measurements
Patient’s delirium severity and benzodiazepine use were monitored over 5 days after the diagnosis of delirium.Main results
Delirium Index decreased over time in both groups, as did the administered dose of benzodiazepines. Clinical improvement was similar in both treatment arms. No side effects were noted in the olanzapine group, whereas the use of haloperidol was associated with extrapyramidal side effects.Conclusions
Olanzapine is a safe alternative to haloperidol in delirious critical care patients, and may be of particular interest in patients in whom haloperidol is contraindicated.8.
Yuichiro Hayashi Kazunari Misawa Masahiro Oda David J Hawkes Kensaku Mori 《International journal of computer assisted radiology and surgery》2016,11(5):827-836
Purpose
Knowledge of the specific anatomical information of a patient is important when planning and undertaking laparoscopic surgery due to the restricted field of view and lack of tactile feedback compared to open surgery. To assist this type of surgery, we have developed a surgical navigation system that presents the patient’s anatomical information synchronized with the laparoscope position. This paper presents the surgical navigation system and its clinical application to laparoscopic gastrectomy for gastric cancer.Methods
The proposed surgical navigation system generates virtual laparoscopic views corresponding to the laparoscope position recorded with a three-dimensional (3D) positional tracker. The virtual laparoscopic views are generated from preoperative CT images. A point-based registration aligns coordinate systems between the patient’s anatomy and image coordinates. The proposed navigation system is able to display the virtual laparoscopic views using the registration result during surgery.Results
We performed surgical navigation during laparoscopic gastrectomy in 23 cases. The navigation system was able to present the virtual laparoscopic views in synchronization with the laparoscopic position. The fiducial registration error was calculated in all 23 cases, and the average was 14.0 mm (range 6.1–29.8).Conclusion
The proposed surgical navigation system can provide CT-derived patient anatomy aligned to the laparoscopic view in real time during surgery. This system enables accurate identification of vascular anatomy as a guide to vessel clamping prior to total or partial gastrectomy.9.
Simon Drouin Anna Kochanowska Marta Kersten-Oertel Ian J. Gerard Rina Zelmann Dante De Nigris Silvain Bériault Tal Arbel Denis Sirhan Abbas F. Sadikot Jeffery A. Hall David S. Sinclair Kevin Petrecca Rolando F. DelMaestro D. Louis Collins 《International journal of computer assisted radiology and surgery》2017,12(3):363-378
Purpose
Navigation systems commonly used in neurosurgery suffer from two main drawbacks: (1) their accuracy degrades over the course of the operation and (2) they require the surgeon to mentally map images from the monitor to the patient. In this paper, we introduce the Intraoperative Brain Imaging System (IBIS), an open-source image-guided neurosurgery research platform that implements a novel workflow where navigation accuracy is improved using tracked intraoperative ultrasound (iUS) and the visualization of navigation information is facilitated through the use of augmented reality (AR).Methods
The IBIS platform allows a surgeon to capture tracked iUS images and use them to automatically update preoperative patient models and plans through fast GPU-based reconstruction and registration methods. Navigation, resection and iUS-based brain shift correction can all be performed using an AR view. IBIS has an intuitive graphical user interface for the calibration of a US probe, a surgical pointer as well as video devices used for AR (e.g., a surgical microscope).Results
The components of IBIS have been validated in the laboratory and evaluated in the operating room. Image-to-patient registration accuracy is on the order of \(3.72\pm 1.27\,\hbox {mm}\) and can be improved with iUS to a median target registration error of 2.54 mm. The accuracy of the US probe calibration is between 0.49 and 0.82 mm. The average reprojection error of the AR system is \(0.37\pm 0.19\,\hbox {mm}\). The system has been used in the operating room for various types of surgery, including brain tumor resection, vascular neurosurgery, spine surgery and DBS electrode implantation.Conclusions
The IBIS platform is a validated system that allows researchers to quickly bring the results of their work into the operating room for evaluation. It is the first open-source navigation system to provide a complete solution for AR visualization.10.
Anna Belkova David R Pichora Randy E Ellis 《International journal of computer assisted radiology and surgery》2016,11(4):521-527
Purpose
Image-guided interventions that use preoperative 3D computed tomography (CT) models are limited by the preoperative segmentation time 3D image and collection of intraoperative registration data. Intraoperative CT imaging can be ergonomically efficient in a direct navigation system if the imaging device is accurately calibrated. A mobile-gantry CT scanner offers improved patient safety but presents technical challenges beyond those of a conventional scanner. The goal was to calibrate an optoelectronic navigation system to mobile-gantry CT with millimeter-level accuracy.Methods
A custom calibration device was designed and manufactured. The calibrator contained optoelectronic markers for navigation reference and radio-opaque markers for CT reference. Calibrations were performed with a ceiling-mounted optoelectronic camera and with a portable camera, and then verified for accuracy.Results
The component fiducial registration errors were extremely small, being 0.36 mm, with standard deviation of 0.16 mm, for the ceiling-mounted camera, and 0.05 mm, with standard deviation of 0.01 mm, for the portable camera. The net target registration error, measured as RMS deviation, was 1.58 mm for the ceiling-mounted camera and 0.73 mm for the portable camera.Conclusions
High-accuracy calibration of the mobile-gantry CT scanner was possible from a single preoperative CT image. A ceiling-mounted optoelectronic camera, which is ergonomically preferable, marginally met the accuracy criteria. The portable camera, which is in widespread use for conventional navigated surgery, had deep sub-millimeter error. This study demonstrates that high accuracy is achievable and offers a system developer options to trade off accuracy and user convenience in direct surgical navigation.11.
Background
The use of a scientifically developed App for pain management in the home care setting is not yet established in Germany. The documentation of pain-specific data by the patients and the transfer into a web portal to be examined by the attending physician can help close the existing communication gap in pain management between consultations.Objectives
The aim of the study was to develop a mobile health (mHealth) solution for optimizing pain management in the home care setting. The research questions focus on design and technical issues concerning layout and navigation of the painApp as well as user-relevant questions concerning pain management, such as pain at rest and pain during movement, taking pain medication and patient satisfaction with their pain situation.Materials and methods
Within a 12-month period, the user-centered development and practice-based testing of the application painApp involved patients aged?≥?65 years. Within a formative evaluation, a total of four data collections and a final survey took place. During the same period, a web portal was developed and tested the documentation of the patient pain-specific data from the painApp with the participation of general practitioners.Results and conclusions
The development of the painApp as a prototype was realized in the study with high acceptability by the patients. The painApp is able to establish digital communication with the general practitioner without any technical problems and allows the physician access to patient data in real time.12.
Masashi Hirooka Yohei Koizumi Yusuke Imai Hironori Ochi Yoshiko Nakamura Osamu Yoshida Atsushi Hiraoka Yoshio Tokumoto Masanori Abe Yoichi Hiasa 《Journal of Medical Ultrasonics》2016,43(2):185-191
Purpose
The purpose of this study was to assess the accuracy and efficacy of a needle-tracking system in phantom and clinical studies using bipolar electrodes.Methods
To observe the tip of the electrode, a needle-tracking system with a volume navigation system was used. In the phantom study, the electrode was inserted at various angles and the error was verified. In the clinical study, 21 nodules close to extrahepatic organs or major vessels were enrolled between May and October 2014. After puncturing with the needle-tracking system, computed tomography (CT) was performed. The distances between the electrode tip and extrahepatic organs or major vessels were measured on both B-mode ultrasound (US) and CT. By comparing these distances, the accuracy of this system was evaluated.Results
In the phantom study, the deviation between the tip of the electrode and the virtual tip of the electrode was analyzed. The median values were within 2 mm at each puncture angle. In the clinical study, the difference between B-mode US and CT was less (mean value 1.17 ± 1.76 mm; range 0–3.5 mm).Conclusion
The needle-tracking system is an accurate and useful system for bipolar radiofrequency ablation.13.
Yuichiro Hayashi Kazunari Misawa David J. Hawkes Kensaku Mori 《International journal of computer assisted radiology and surgery》2016,11(5):837-845
Purpose
A surgical navigation system supports the comprehension of anatomical information during surgery. Patient-to-image registration is the alignment process between CT volume and patient coordinate systems. Achieving accurate registration in the surgical navigation of laparoscopic surgery is very challenging due to soft tissue deformation. This paper presents a new patient-to-image registration method based on internal anatomical landmarks for improving registration accuracy in the surgical navigation of laparoscopic gastrectomy for gastric cancer.Methods
Our proposed registration method progressively utilizes internal anatomical landmarks. In laparoscopic gastrectomy for gastric cancer, the surgeon cuts the blood vessels around the stomach. The positions of the cut vessels are sequentially used as fiducials for registration during surgery. The proposed method uses a weighted point-based registration method for computing the transformation matrix using the fiducials both on the body surface and on the blood vessels. When a blood vessel is cut during surgery, the proposed progressive registration method measures the cut vessel’s position and computes a transformation matrix by adding the cut vessel as a fiducial.Results
We applied our proposed progressive registration method using the positional information of the blood vessels acquired during laparoscopic gastrectomy in 20 cases. We evaluated it using target registration error in four blood vessels. The average target registration error in the four blood vessels was 12.6 mm and ranged from 2.1 to 32.9 mm.Conclusion
Since the proposed progressive registration can reduce registration error, our proposed method is very useful for the surgical navigation of laparoscopic gastrectomy. Our proposed progressive registration method might increase the accuracy of surgical navigation in laparoscopic gastrectomy.14.
15.
Introduction
To present short-term safety and efficacy data of men with lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH) treated with Aquablation.Methods
Men with LUTs secondary to BPH (60–150 cc) underwent Aquablation treatment from February 2016 to December 2017 across 17 investigational sites in the USA from two contemporary investigational device exemption (IDE) studies called WATER (NCT02505919) and WATER II (NCT03123250).Results
One hundred seven males with mean age of 67.3?±?6.5 years were treated with Aquablation; mean prostate volume was 99.4?±?24.1 cc. The pooled results show that large prostates have an average procedure time of less than 36 min and discharge on average 1.6?±?1 days. The IPSS decreased by 16.7?±?8.1 points at 3 months and Qmax increased by 11.2?±?12.4 ml/s. The Clavien-Dindo (CD) grade 2 or higher event rate at 3 months was 29%. A non-hierarchical breakdown for CD events yielded 18% grade 2 and 19% grade 3 or higher.Conclusion
Men with LUTS secondary to BPH (60–150 cc) in a pooled analysis were treated safely and effectively with Aquablation up to 3 months postoperatively.Trial Registration
ClinicalTrials.gov identifiers, NCT02505919 and NCT03123250.Funding
PROCEPT BioRobotics.16.
Tobias Frank Axel Krieger Simon Leonard Niravkumar A. Patel Junichi Tokuda 《International journal of computer assisted radiology and surgery》2017,12(8):1451-1460
Purpose
With the growing interest in advanced image-guidance for surgical robot systems, rapid integration and testing of robotic devices and medical image computing software are becoming essential in the research and development. Maximizing the use of existing engineering resources built on widely accepted platforms in different fields, such as robot operating system (ROS) in robotics and 3D Slicer in medical image computing could simplify these tasks. We propose a new open network bridge interface integrated in ROS to ensure seamless cross-platform data sharing.Methods
A ROS node named ROS-IGTL-Bridge was implemented. It establishes a TCP/IP network connection between the ROS environment and external medical image computing software using the OpenIGTLink protocol. The node exports ROS messages to the external software over the network and vice versa simultaneously, allowing seamless and transparent data sharing between the ROS-based devices and the medical image computing platforms.Results
Performance tests demonstrated that the bridge could stream transforms, strings, points, and images at 30 fps in both directions successfully. The data transfer latency was <1.2 ms for transforms, strings and points, and 25.2 ms for color VGA images. A separate test also demonstrated that the bridge could achieve 900 fps for transforms. Additionally, the bridge was demonstrated in two representative systems: a mock image-guided surgical robot setup consisting of 3D slicer, and Lego Mindstorms with ROS as a prototyping and educational platform for IGT research; and the smart tissue autonomous robot surgical setup with 3D Slicer.Conclusion
The study demonstrated that the bridge enabled cross-platform data sharing between ROS and medical image computing software. This will allow rapid and seamless integration of advanced image-based planning/navigation offered by the medical image computing software such as 3D Slicer into ROS-based surgical robot systems.17.
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.18.
M. Tröger 《Arthroskopie》2016,29(3):179-185
Background
Knees with a limited range of motion caused by intraarticular scars benefit from arthroscopic arthrolysis. Usually these scars result from previous surgery, severe trauma with damage of intraarticular structures.Objectives
The aim of this procedure is to improve the patients’ range of motion which is necessary for activities of work and daily life. Scar tissue is debrided and resected arthroscopically with a radiofrequency device, a shaver or a punch.Indications
Indications are a flexion deficit of max. 40°, an extension deficit of max. 20°, reduced mobility of patella, intraarticular reason for limited range of motion, cyclops after anterior cruciate liagment reconstruction, fibrotic Hoffa fat pad.Contraindications
Contraindications are an extraarticular origin of limited range of motion (e.?g. fibrotic quadriceps muscle), local and general infection, major osteoarthritis, noncompliance, complex regional pain syndrome type I.Postoperative management
A continuous physical therapy to maintain range of motion is essential. If necessary, continuous passive motion is implemented. Pain adapted weight-bearing should be used for mobilization. A sufficient oral and (when indicated) regional pain management is important to guarantee the benefit of the surgery.Results
Patients with a lack of mobility of the knee gain a significantly increased range of motion by this arthroscopic procedure. Because of the minimal invasiveness, trauma of surgery and risk of infection are reduced. In many cases the function of the knee joint can be completely restored or at least improved considerably. Complications such as early osteoarthritis can be avoided.19.
Background
The in part promising, in part discrepant efficacy of psychological treatment of chronic musculoskeletal pain indicates a demand for interdisciplinary assessment and corresponding treatment structures with differentiated degrees of psychological and syndrome-specific specialization within a multimodal orthopedic context. Acceptance of pain and psychological flexibility are strongly related to physical impairments caused by pain.Objective
Goals are improved outcomes of medical and physical treatment measures as well as their flexible implementation in daily life through a differentially indicated psychological pain therapy focusing on pain acceptance and mindfulness.Methods
This study employed the “active not doing and generating inner silence” exercise from mindful-based pain therapy (“Achtsamkeitsbasierte Schmerztherapie”, ABST).Results
Pure observation of a problem without an attempt to solve it is unusual and strange. Prerequisites for such exercises are willingness to engage as well as courage and openness.Conclusion
A differentiated indication for clinical psychological treatment or psychotherapy of pain—a highly specialized form of psychological pain therapy—should be based on the diagnostic criterium of pain acceptance.20.