Psychologisches Prophylaxetraining zur Bewältigung postoperativer Schmerzen

Introduction

The present study was performed to investigate the effect of multidimensional psychological prophylaxis training focusing on coping with cognitive-emotional pain on recovery within the first 12 months after surgery. The training included the following three components: (1) education about pain, analgesia and psychological aspects of coping with pain, (2) training for coping with pain and (3) body-centered relaxation.

Material and methods

In the study 48 young male patients (surgical correction of a chest malformation) were assessed 1 day before surgery, at discharge and 3, 6 and 12 months postoperatively concerning postoperative pain intensity and pain disability as well as pain anxiety, pain catastrophizing and pain hypervigilance. Additionally, 24 of these patients received training on cognitive-emotional coping with pain 1 day before surgery and 1–3 days after surgery (each session 1 h).

Results

The proportion of patients with clinically relevant improvement was significantly higher in the training group compared to the control group. This was the case for acute pain intensity (approximately 1 week after surgery), pain disability 3 months later and pain anxiety 12 months after surgery.

Conclusion

The resurgence of pain anxiety after 12 months could only be found in the control group and could be due to the upcoming surgical removal of the transsternal metal implant. The prophylaxis training can therefore be seen as a protective factor for long-term management of surgery-related consequences and future pain experiences.     

Die Bedeutung der Änderungsbereitschaft des Transtheoretischen Modells (TTM) für den Verlauf der Bewältigung chronischer Schmerzen

BACKGROUND: Motivation in the concept of the transtheoretical model (TTM) is the readiness to change attitudes and behaviour. According to this patients with chronic pain pass through different stages of change (precontemplation, preparation, action, maintenance) before they adopt a new behaviour (e.g. relaxation exercise). This study analyses the impact of readiness to change over the course of 3 months. METHODS: Different questionnaires [coping with pain, impairment of pain, self-efficacy expectations and the German version of the Pain Stages of Change Questionnaires (PSOCQ), the FF-STABS] were administered two times to 74 patients of a rehabilitation clinic. Statistical analysis of covariance (SAS PROC MIXED) was used to analyse the relevance of the stages of change for the course of coping with chronic pain. RESULTS AND CONCLUSIONS: The stages of preparation, action and maintenance show statistically significant interrelations with coping with chronic pain subscales, and precontemplation covaries significantly with impairments of pain. The data suggest the relevance of the "readiness to change" concept for the realization of appropriate coping with chronic pain.     

Prävalenz chronischer Schmerzen in Deutschland

Background

There are no up to date data from representative samples of the general German population on the prevalence of debilitating pain and of pain diseases available.

Methods

A cross-sectional survey of a representative sample of the German general population including persons ≥?14 years of age was conducted in 2012 based on face-to-face interviews using standardized questionnaires. Chronic pain was assessed by the widespread pain index (WPI), disability by the subscales physical functioning and role function of the European Organisation for Research and Treatment of Cancer (EORTC QLQ-C30) and psychological distress by the patient health questionnaire (PHQ-4). Chronic pain with associated physical and social impairments was defined by at least one pain site over 3 months in the WPI and at least one response of a moderate or severe impairment in both subscales of the EORTC 30 QLQ-C30. Chronic pain with associated physical, mental and social impairment (pain disease) required in addition a probable depressive and/or anxiety disorder in the PHQ-4.

Results

A total of 2,515 out of 4,480 (56.1 %) of contacted persons finished the study of which 32.9 % reported chronic pain, 5.4 % reported chronic pain with associated physical and social impairments and 2.3 % associated physical, mental and social impairments. No participants with local pain (only one pain site) but 24.0 % of participants with widespread pain (6–19 pain sites) met the criteria of a pain disease.

Conclusions

The reports of chronic pain in epidemiological studies do not necessarily imply a suffering (physical, psychological and social impairment) from pain.     

Verhaltensbeobachtung zur Erfolgsmessung einer Rückenschule zur Prävention chronischer Schmerzen

Sixteen experienced and 15 inexperienced observers watched videotapes showing participants of a back school program perform simple tasks to assess the functional adequacy of their posture. They had received basis or more extensive observer training. Intraclass correlation coefficients were computed as a measure of intra-and interobserver reliability. When individual judgments were compared, it was found that the judgments of the experienced observers were more reliable than those of the inexperienced observers. The additional observers training did not lead to a significant augmentation of reliability. By selecting the most reliable items two alternative measures of overall posture were constructured whose reliability coefficients ranged fromr=0.89 to 0.93 for the group of experienced observers. The reliability of the judgments by the more extensively trained inexperienced observers was also satisfactory. The observation method presented here can thus be regarded as a reliable and potentially valid instrument for assessing the outcome of back school programs.     

Einfluss präoperativer Patienteninformationen auf postoperative Schmerzen unter Berücksichtigung individueller Stressverarbeitung

Objective

The German guideline for the treatment of acute perioperative and post-traumatic pain (S3-Leitlinie zur Behandlung akuter perioperativer und posttraumatischer Schmerzen) recommends giving preoperative information about postoperative pain and how to influence it. It is expected that the effect of preoperative information is modified by psychological characteristics of the patient. One of these psychological characteristics is the individual coping style. The purpose of the study is to evaluate whether or not patients benefit from preoperative education in relation to their level of negative coping style.

Methods

The study is based on a 2×2 factorial experimental design with the experimental factor “treatment” (education vs control condition) and the factor “negative coping style” (high vs low). After informed consent 96 patients undergoing abdominal or vascular surgery were enrolled in the study. Outcomes were pain intensity, pain quality and psychic state. They were assessed by using numerical rating scales and psychometric methods of self-assessment. The data were collected preoperatively and on the first to third postoperative day.

Results

Patients who received preoperative education experience a greater reduction in postoperative pain than patients without preoperative education do (ES=0.48). The risk for stronger pain (NRS>3) on the third postoperative day is decreased (2.1 vs 14.6%). The influence of negative coping style is altogether minimal.

Conclusions

Preoperative patient information has positive effects on the postoperative development of pain. Patient information is a valuable addition to the drug pain treatment. The application can be recommended regardless of the level of the patients’ negative coping style     

Einfluss von Zahnveränderungen auf die Körperhaltung

Background

Alterations in body posture as well as in functional movements have been observed after application of oral devices. This effect has been attributed to the stomatognathic system and is thought to be causally dependent on occlusion. In consequence, occlusion has become the dominant target in dental diagnostics and therapy, although conclusions of investigations have remained controversial for decades.

Hypotheses

However, it is more likely that the alterations in body posture develop from the postural system: the alterations have to be considered as a static restructuring of body posture as a reaction to shifting of a basic indicator of the postural system. This seems to be a reference layer which is elementarily needed for the spatial orientation of the postural system. The length of upper jaw teeth contributes to this reference layer and changes in tooth length will therefore cause an adaptation of body posture. This leads to the assumption that the structures located in the area of the jaws and teeth form the basis not only for stomatognathic function but also for postural function where they are basically needed in processing information for spatial orientation and body posture. Application of oral wafers can also cause the shifting of this postural reference layer and lead to an alteration of body posture.

Results

Dental diagnostics and therapy should benefit from considering the spatial position of the jaw and other body structures in order to prevent unfavorable alterations in posture. Before focusing on occlusion dentists should first aim at finding the optimal position of the postural reference layer in the skull.     

Epidurale R��ckenmarkstimulation zur Therapie chronischer Schmerzen

Epidural spinal cord stimulation (SCS) is a reversible but invasive procedure which should be used for neuropathic pain, e.g. complex regional pain syndrome I (CRPS) and for mostly chronic radiculopathy in connection with failed back surgery syndrome following unsuccessful conservative therapy. Epidural SCS can also successfully be used after exclusion of curative procedures and conservative therapy attempts for vascular-linked pain, such as in peripheral arterial occlusive disease stages II and III according to Fontaine and refractory angina pectoris. Clinical practice has shown which clinical symptoms cannot be successfully treated by epidural SCS, e.g. pain in complete paraplegia syndrome or atrophy/injury of the sensory pathways of the spinal cord or cancer pain. A decisive factor is a critical patient selection as well as the diagnosis. Epidural SCS should always be used within an interdisciplinary multimodal therapy concept. Implementation should only be carried out in experienced therapy centers which are in a position to deal with potential complications.     

Anamnesen und Verlaufsprotokolle chronischer Schmerzen für die Praxis— Ein Überblick

This article reviews the methods currently in use for the measurement of chronic pain. The most important items for inclusion in questionnaires about the history and in pain diaries to elicit data on the time-course of pain are presented, and both the aims and the advantages and disadvantages of various strategies are discussed. The documentation of chronic pain in outpatients would allow answers to some questions concerned with medical epidemiology if practiced in a large number of therapeutic institutions, especially if the data were processed and evaluated by microcomputer.     

Einfluss von Akupunktur auf postoperative Schmerzen, Übelkeit und Erbrechen nach viszeralen Eingriffen

Background

The objective of this study was to assess repeated needle acupuncture in the treatment of postoperative pain and nausea after visceral surgery.

Material and methods

Sixty-six patients undergoing visceral surgery (hysterectomy, cholecystectomy) were randomly assigned to group A (three sessions of needle acupuncture, n=21), group M (3x1000 mg metamizole, n=20), or group K (control, n=25). All patients received patient-controlled analgesia (PCA) using piritramide. To adjust for nonspecific effects due to physician–patient interaction during acupuncture sessions in group A, patients in groups M and K also received three standardized visits. Primary outcome parameters were defined as pain intensity, analgesic consumption, and frequency of nausea and vomiting in a period up to the morning of the second postoperative day.

Results

Patients in group A reported significant less pain, nausea, and vomiting compared to patients in group K. Mean cumulative piritramide consumption was significantly lower in group A (25.0 mg) than in group M (34.5 mg) and group K (55.2 mg).

Conclusion

Repeated needle acupuncture may be effective in postoperative pain relief and the treatment of nausea and vomiting in the postoperative period. These effects seem not to be due solely to interaction between the acupuncturist and the patient.     

Einfluss lokaler Anästhetika auf den hyalinen Gelenkknorpel

Background

The cytotoxicity of local anesthetics on articular hyaline cartilage is particularly noticeable in the use of continuous infusion pain pumps. This can result in the onset of chondrolysis.

Methods

Bupivacaine in particular but also mepivacaine, ropivacaine and lidocaine, have shown cytotoxic effects on hyaline cartilage in multiple in vitro and in vivo studies.

Results

Whether a single intra-articular administration of local anesthetics is sufficient to result in apoptosis of articular hyaline cartilage is unclear; however, the currently published dose response studies revealed that increasing concentrations and contact times of local anesthetics result in progressive cell damage to articular cartilage. The studies used different cell and culture systems as well as different animal models; therefore, the results are partly divergent and it is difficult to extrapolate the threshold levels of cytotoxic concentrations to the routine clinical practice.

Conclusion

According to the currently available data, the indications for intra-articular injection of local anesthetics should be interpreted with caution. Intra-articular administration via continuous infusion pain pumps should no longer be used.

     

Einfluss von kognitiv-emotionalen Prozessen auf Schmerz und Funktionsbeeinträchtigung

In the context of the biopsychosocial pain concept and on the basis of empirical evidence those cognitive traits and mechanisms are described that have reliably been found to be potent moderators of pain and disability. Expectations of patients which result in placebo or nocebo effects as well as more complex belief patterns influence subjective pain severity as well as disability. Especially beliefs which relate to self-control, self-efficacy or its counterpart helplessness can distinctly moderate pain, lead to an increase or mitigation of pain intensity and associated disability. The impact of most of these cognitive factors, such as catastrophizing, low self-efficacy, certain pain beliefs, low acceptance or fear of pain can be integrated into the general stress coping model. It denominates situational appraisal and self-appraisal processes beside actual coping behaviors as the main psychological factors influencing severity of pain and related disability.     

Einfluss der Okklusion auf die plantare Druckverteilung beim Barfußlaufen

Objective

The aim of this pilot study was to analyze the effects of various dental occlusion positions on barefoot running behavior.

Material and methods

The six healthy subjects with a good endurance training status ran for 5 min at a speed of 10 km/h on a treadmill at each set of conditions. At the end of each set of measurement conditions the plantar pressure distribution was recorded. In addition to the resting position three different measurement conditions were recorded: the occlusion in centric condylar position (centric splint), myocentric position (DPS splint) and maximum intercuspidation.

Results

At the maximum length of the walking line of the right foot significant differences could be detected between the resting position and the maximum intercuspidation position, the centric splint and DPS splint and the DPS splint and the maximum intercuspidation position. The mean length of the walking line of the right foot showed significant differences between the resting position and maximum intercuspidation position, centric splint and DPS splint and DPS splint and intercuspidation position. The comparison between the DPS splint and the maximum intercuspidation splint was significant with respect to the maximum pressure in the left midfoot area.

Conclusion

In this pilot study barefoot running altered most while wearing the DPS splint and the maximum intercuspidation splint. These conditions showed in comparison to the resting position or the centric splint a lengthening/shortening of the walking line of the right foot and simultaneously a left-sided decrease/increase of the maximum pressure in the midfoot. As these parameters varied least while wearing the centric splint and at resting position, it was presumed that this splint is the best. A complete assessment of these trends is not yet possible due to the small number of subjects.     

Haben das visuelle und sensomotorische System Einfluss auf die Kiefermuskulatur?

Background

The visual and sensorimotor systems of the human organism perceive conscious but also unconscious internal and external stimuli which are processed in the central nervous system. In this respect muscle-related effects of these systems can effect the condylar position and movement of the mandible. The following pilot study was carried out to investigate this possibility.

Material and methods

This study was conducted with 10 adults with complete dentures and complaints of the musculoskeletal system. The documentation of horizontal jaw relationship was measured by an intraoral needle point tracing system. First the initial position was measured and after that a measurement with closed eyes was recorded. A third measurement was taken after a specific change in body posture on the sensorimotor system by individual placement of sensorimotor elements. For statistical data analysis the Wilcoxon matched-pairs test was used.

Results

If the visual system is excluded in the implementation of the prescribed movements, the only change is the final excentric condylar position (p=0.05). The initial excentric condylar position moves mesially due to the influence of the elements (p=0.02) and the centric condylar position is shifted to the left on the x-axis (p=0.02). The protrusion moves to the left (p=0.03) and the motion of the left side is increased (p=0.03).

Conclusion

Both the visual and the sensorimotor systems are able to effect changes in the determination of horizontal jaw relationships. The placement and therefore the effects of the elements must always be assessed on an individual basis.     

Einfluss von Achtsamkeitsübungen und Meditation auf die haptische Wahrnehmung

Background

Osteopathic therapists and physicians preferably work with their hands for diagnostics and therapy by means of palpation and perception. The influence of meditation and attentiveness training on alterations in haptic perception and the haptic threshold are presently unknown.

Subjects and methods

Within the framework of this pilot project the haptic threshold of ten persons was tested before and after 1 week of meditation and attentiveness training, consisting of yoga, gait meditation and silent meditation.

Results

A significant improvement (p?=?0.028) of the haptic threshold could be demonstrated between the first and second measurements. No significant age-related correlation according to Pearson could be found.

Conclusion

Positive alterations in the haptic threshold could be demonstrated after intensive training of meditation and attentiveness. This shows interdependence between the influence on the consciousness and the attentive perception of active tactile sense which plays a decisive role in manual osteopathic medicine. Further studies are necessary in order to confirm the results of the pilot study.     

Effekte einer Okklusionsschiene auf die Oberkörperstatik beim HWS-Syndrom

Aims

The aim of the study was to investigate how the movement functions of the cervical spine, shoulder and pelvic regions and the symptomatic of patients alter while using an occlusal splint for patients with problems in the cervical spine and shoulder-neck region.

Probands and methods

A total of 34 patients aged between 19 and 72 years participated in the study (12 males and 12 females). Following the initial admission examination all subjects wore an occlusal splint in a centric relation position which has to be worn at night over a period of 6 weeks. The entrance and termination investigations of posture were documented according to a manual therapeutic investigation scheme and with a 3-D back scanner.

Results

The results of the 3-D back measurements showed differences in the spinal and pelvic parameters. In the manual therapeutic examination alterations were found particularly in shoulder height and rotation and also alterations in pelvic rotation with respect to the height of the iliac crest and differences in leg length.

Discussion

The documented results of this study indicate that effects of the craniomandibular system have an influence on body posture due to an occlusal splint. However, the 6-week study period of wearing the splint seems to be too short to be able to draw conclusions. Because each examination method gives different results, the combination of manual therapeutic examination and technical measurement methods for diagnostics and control of therapy with an occlusal splint in the dental orthodontic course of treatment seems to be appropriate.     

Einfluss der CMD auf die mechanische Schmerzschwelle außerhalb der Kopf-Gesichts-Region

Background and objective

There is currently no evidence of changes in pressure sensitivity of myofascial trigger points (MTrPs) in extra-trigeminal regions in patients with craniomandibular dysfunction (CMD). The purpose of this study was to evaluate whether pressure sensitivity of MTrPs in patients with CMD increases in trigeminal and extra-trigeminal regions compared to a healthy control group. Furthermore, the extent to which MTrPs can be used as diagnostic markers for hyperalgesia in patients with CMD was investigated.

Subjects and methods

In this study 34 patients with CMD (15–64 years old) and 30 healthy control subjects (22–65 years old) were included. The pressure pain threshold of MTrPs in trigeminal and extra-trigeminal regions was measured and compared. Additionally, the most suitable diagnostic marker of hyperalgesia in patients with CMD was investigated using ROC curve analysis.

Results

Pressure sensitivity of all MTrPs was significantly increased in the CMD group. Even after correction for multiple testing, most of the effects continued to be significant. The trapezius muscle was the most suitable among all MTrPs for the classification of hyperalgesia in patients with CMD. Assuming a false positive rate of below 5?%, 42?% of patients with CMD were classified as hyperalgetic.

Discussion

The significant differences in pressure sensitivity of MTrPs in trigeminal and extra-trigeminal regions indicate that hyperalgesia is present in patients with CMD. The trapezius muscle might be a marker for diagnosing hyperalgesia. Further studies are required in order to identify gender and age-specific indicators.