Die Cortisol-Aufwachreaktion bei Patienten mit akuten und chronischen Rückenschmerzen

Background

Peculiarities of the hypothalamic-pituitary-adrenal axis activity in stress-related pain-disorders and potential relations with psychological risk factors of pain chronicity have been discussed controversially.

Material and methods

The cortisol awakening responses of 31 low back pain patients (14 acute, 17 chronic) and 14 healthy controls were compared. In addition the interrelations between awakening response and chronic stress as well as depressive mood and – for the first time – maladaptive painprocessing and -copingstrategies were investigated.

Results

The groups did not differ in their cortisol awakening responses. Chronic stress, depressive mood and maladaptive cognitive painprocessing did not correlate with the awakening response. There were, however, significant interrelations between awakening responses and the behavioral paincoping-strategies.

Conclusions

Behavioral paincoping-strategies should be considered as a potentially important contributing psychological factor in the relation between the activity of the hypothalamic-pituitary-adrenal axis and stress-related pain disorders.     

Lebensqualität und alexithyme Merkmale bei Patienten mit somatoformer Schmerzstörung

Background

Patients with somatoform pain disorders (SPD) frequently display reduced quality of life (QoL) and increased levels of alexithymia. This study investigated the association of QoL and alexithymia in a sample of SPD.

Patients and methods

Fifty-one patients with SPD (average time since onset: 11.6 years) were assessed in terms of alexithymia (TAS-20), QoL (WHOQOL-BREF), psychological distress and somatisation (SCL-90-R), and depression (MADRS).

Results

In SPD patients a significant negative correlation was observed between QoL and alexithymia, particularly the psychological domain of QoL and the TAS-20 total score (r=–.63, p<.001). The TAS-20 subscale “Difficulty Describing Feelings” was revealed to be a significant predictor of the psychological domain of QoL (β=–.34, p<.01), even after controlling for depression, somatisation and gender.

Conclusion

Patients with SPD show a remarkably reduced QoL and alexithymia appears to play a significant role for low QoL. Clinicians need to pay careful attention to alexithymia with regard to diagnosis and treatment planning in SPD patients.     

Komorbidität bei Patienten mit chronischen Rückenschmerzen

BACKGROUND: Studies concerning comorbidity in patients with chronic low back pain and its correlation to the stage of chronification are rare. METHODS: This case-control study (matched-pair analysis) examines the number and specificity of comorbidity as well as the extent of disability due to comorbidity in 51 patients with chronic low back pain compared to age- and sex-matched control persons. Moreover, the correlation of comorbidity and the stage of chronification was analysed in these patients. RESULTS: Patients with chronic low back pain had significantly more comorbidities and a higher disability due to comorbidity compared to the control persons. The higher the stage of chronification according to the Mainz Pain Staging System (MPSS) the higher was the number of comorbidities. CONCLUSION: Comorbidity should be given due consideration when evaluating diagnosis, therapy, prognosis and therapy outcome in patients with chronic low back pain.     

Bessere Verlaufsdokumentation bei Patienten mit lumboradikul?ren Schmerzsyndromen

Background

The purpose of the study was to present a reliable instrument with easy application to assess the outcome and improvement of therapy in patients with radicular symptoms of the lumbar spine.

Methods

Data from patients who underwent microdiscectomy because of lumbar radicular symptoms were collected and analyzed and interviews were performed using the well-known North American Spine Society (NASS) lumbar spine questionnaire (17?items) before and after the intervention. In addition patient data including comorbidities were collected. By calculating effect size (ES) and standardized response mean (SRM) for each item of the questionnaire, the questions with the highest change before and after the intervention could be selected.

Results

A total of 139 patients undergoing microdiscectomy for lumbar radicular symptoms due to a disc herniation were included in the analysis. Concerning the three dimensions pain, neurological symptoms and impairment of activities in daily life, the questions with best predictive value (high ES and SRM) were selected. According to their clinical relevance eight questions of the NASS questionnaire were finally selected for the short form.

Conclusion

This short, significant and easy to use questionnaire is in our opinion a useful instrument to assess the course of patients with radicular back pain and especially to measure and monitor the outcome of therapeutic interventions, in addition to conventional clinical diagnostics and examinations. This novel instrument could be a useful tool for improving quality assurance in conventional and interventional pain management of these patients.     

Schmerzen und Funktionsstörungen der Lendenwirbelsäule bei lumbalen Bandscheibenvorfällen

In this study we attempted to explore the correlation between lumbar disc herniation and functional disorders of the lumbar spine. Fifty patients with lumbar disc herniation proven by computed tomography underwent a comprehensive functional, neurological and radiological examination. All patients were compared to a control group consisting of 16 healthy subjects of comparable age. Only patients without signs of bone or soft tissue alterations or pregnancy at the time of examination were included into the study. Herniations of the L4-5 disc showed a dysfunction in the same segment in 64% of the cases. There was also a correlation between this segmental dysfunction and pain in the sacrotuberal and iliolumbar ligaments. All patients with segmental dysfunction felt pain in the dorsal ligaments. If there was no segmental dysfunction pain in the dorsal ligaments was encountered just as often as in the control group. Herniations of the L5-S1 disc had a dysfunction in the same segment in only 12% of the cases, but in 35% there was dysfunction of the L4-5 motion segment. In this group pain in the dorsal ligaments did not correlate with segmental movements. Frequency of ligamental pain in L4-5 herniations was equal to that in L5-S1 herniations. With increasing size of the disc herniation, the frequency of segmental dysfunction, paralysis and loss of reflexes also increased, but the pain in the dorsal ligament decreased.Segmental dysfunction is explained by increased muscular tone being provoked by irritation of the sinuvertebral nerve. The differences between L4-5 and L5-S1 movements are probably due to the different functional anatomy of these segments. Ligamental pain may be explained by the fact that these ligaments have the same insertion and the muscles have increased in tone.     

Selbstmanagement in der Manualtherapie bei Patienten mit chronischen Rückenschmerzen

Chronic non-specific back pain usually has no direct association with a measurable pathology. Nevertheless, affected patients can experience significant functional impairment in their everyday lives and work. As such, several individual findings, particularly on a psychosocial level, go to make up the overall clinical presentation. If acute symptoms persist despite the sound application of effective techniques or if pain has already become chronic, an interdisciplinary assessment should be considered. Guideline-compliant multimodal interdisciplinary treatment comprises various components: intensive education that takes a biopsychosocial disease model into account, medicinal pain therapy, physiotherapy, everyday training, stress management and sports therapy. To guarantee long-term success, it is essential to integrate an appropriate self-management program into everyday life in order to cope with back pain. This article discusses the aim, content, and implementation of a self-management program of this type.     

Kraniosakrales System und Funktionsstörungen der oberen HWS bei Säuglingen

Background

It was the aim of this study to find out if the manual -medical treatment of the head joints of KTSS- children with kinematic imbalances due to suboccipital strain (KISS) can cause a change/modificoation of their facial dissymmetry and thus-by this— of the faulty position and function of the bones.

Material and methods

In the surgery 30 infants/babies with functional. disturbances of the head joints and a typical dissymmetry of the face, the skull, and the bearing were examined/treated by means of manual therapy and osteotherapy.

Results

In 20 cases there was a very great or great improvemenat of the facial dissymmetry. The status of 10 children remained unchanged. The dissymmetry of the eyes improved in 23 cases whereas there was no change infor seven 7 children. The cranial dissymmetry became better in 2’1 cases, but remained unchanged in 9 cases.

Conclusion

The effects of manual therapy on infants/Bbabies can be partially understood and explained by eliminating theseas secondary adaptive reactions of the cranio-sacral system in the forim of a torsional lesion of the SBS.     

Veränderte Schmerzschwellen während und nach Opioidentzug bei Patienten mit chronischen Rückenschmerzen

Background

Opioids as the strongest pain drugs are often used for chronic pain although their long-term efficacy has not yet been clarified. In this longitudinal study, we compared the pain sensitivity of patients with chronic low back pain (cLBP) under long-term opioid use and treated with multidisciplinary pain therapy.

Methods

The pain sensitivity was measured by the quantitative sensory testing (QST) technique at admission, discharge and 6 months after the beginning of the study in 34 patients with both cLBP and opioid medication, 33 opioid-naive cLBP patients and those neither with pain nor opioid use (HC). Both patient groups underwent a 3-week multidisciplinary pain therapy (MDPT).

Results

Under opioid use, the patients showed significantly lower cold and heat pain thresholds compared to HC and delayed reaction to warm stimuli. After 3 weeks of MDPT, opioid-positive patients still had a lower pain threshold to cold and heat stimuli, while opioid-naive patients normalised their pain perception.

Conclusion

Our findings suggest that long-term use of opioids intensifies the peripheral sensitisation of cLBP. The MDPT can counteract this process.     

EKG-Ver?nderungen bei Patienten mit chronischen Nichttumorschmerzen

Background

Patients with chronic non-cancer pain not only show reduced quality of life, but also chronic morbidity and increased mortality. However, little is known about prevalence and type of abnormal electrocardiogram (ECG) recordings in these individuals.

Material and methods

A total of 100?consecutive patients (≥?18 years) with chronic (≥?3 months) non-cancer pain were examined prospectively using ECG recordings and a questionnaire [German Pain Society (DGSS); further questions]. Data were collected at the first and next two follow-up outpatients’ clinic appointments.

Results

Participation rate was 98%. Of all patients, 26% had an abnormal ECG, while 5% of these patients had an abnormal ECG first at the follow-up when consuming a different analgesic regimen. Findings were QTc prolongation (16%), ventricular block (7%), artrioventricular block (6%), and atrial fibrillation (4%).

Conclusion

The prevalence of abnormal ECG recordings should be considered in the pain management of these patients. General ECG screening in this population should be discussed. Future studies should examine a larger population to identify potential risk factors (e.g., medication).     

Patienten mit vs. ohne psychische Störung in der orthopädischen Rehabilitation

BACKGROUND: In this study it was examined whether orthopedic rehabilitants with versus without a comorbid mental disorder profit from inpatient orthopedic rehabilitation to the same degree. It was also investigated whether there were differential treatment effects between the traditional and behavioral-medical rehabilitation approaches. METHOD: Questionnaires which assess pain-specific and associated variables were issued to a total of 361 patients on admission and discharge from rehabilitation. RESULTS: In some aspects patients with a mental disorder benefited more from the treatment than patients without comorbidities. Differential treatment effects were found only in patients with a mental disorder and improvements were higher in the behavioral-medical than in the traditional rehabilitation approaches. CONCLUSION: Psychological interventions in the inpatient orthopedic rehabilitation are recommended in order to adequately deal with the higher rate of persons with comorbid mental disorders.     

Schmerzen und Funktionsstörungen des Iliosakralgelenks bei Bandscheibenvorfällen der unteren Lendenwirbelsäule

Back and leg pain in patients with lumbar disc herniation can be caused by various mechanisms. In addition to nerve root compression, functional alterations in the sacroiliac joint, facet joint or the iliolumbar and sacrotuberal ligaments can produce "pseudoradicular" lower back syndrome. The following study attempts to show whether or not pain and functional alterations in the sacroiliac joint (SIJ) correlate with herniations revealed by computed tomography (CT). The study also attempts to determine the correlation between pain and functional changes of the SIJ and the size and level of the disc herniation. Fifty patients with monosegmental disc herniations revealed by CT who showed no signs of bone or soft tissue alterations were included in this study. The average duration of the patients' complaints of leg or back pain was 5.7 years. Ninety-six percent of these patients had received conservative treatment before admission to our hospital. All patients were compared to a control group consisting of 16 healthy subjects of comparable age. All patients underwent a comprehensive functional, neurologic and radiologic examination. The CTs were analyzed by a standardized three-dimensional method. All of the 50 patients had sciatica complaints and a disc herniation revealed by CT. In two cases hemiation of the L3-4 disc was demonstrated, in 14 cases L4-5 disc herniation and in 34 cases a L5-S1 disc herniation. In contrast to the control group of 15 healthy subjects, the patients showed a significant number of functional disorders upon examination. In 84% of all patients, movement of the SIJ was restricted. Painful palpation of the symphysis was demonstrated in 46% of all cases. Thirty-five percent of patients with herniation of L4-5 disc demonstrated SIJ tenderness as opposed to 65% of the patients with herniation of the L5-S1 disc. This SIJ tenderness did not correlate with motion of the SIJ. In addition, SIJ motion and frequency of sensory dysfunction showed no correlation with the size of the disc herniation. Paralysis and loss of reflexes showed a positive correlation with the increasing size of the disc herniation. SIJ tenderness decreased as the size of the herniation increased. Dysfunction of the ipsilateral SIJ is explained by increased muscular tone caused by irritation of the n. sinuvertebralis and its lumbar coupling. Frequency of SIJ tenderness is significantly higher in patients with herniations between L5 and S1. Since the SIJ is innervated by the r. dorsalis of the sacral roots, the increased tenderness can be explained by the change in neurovegetative innervation of the SIJ. Due to the high correlation between lumbar disc herniation and SIJ dysfunction, disc herniation should be considered as a possible cause of sacroiliac-joint syndrome.     

Von der Funktionsstörung zur Funktionskrankheit

Background

Despite high acceptance of manual medicine and proven positive for diseases of the locomotor system in particular, it is not recognized by or established in academic medicine. The reason for this might be the lack of a defined therapeutic target. No other medical field is defined by the diagnosis and treatment of clinical findings (somatic dysfunction).

Methods

Based on an expert panel and relevant literature, somatic dysfunction, the development of functional diseases, and factors influencing their chronification are discussed and defined.

Results

The diagnostic and therapeutic target of manual medicine is the functional disease as well as the underlying primary and secondary somatic dysfunction. Functional diseases of the locomotor system are characterized by the following cardinal symptoms: pain and deficits in function, participation, and activities. Somatic dysfunctions are the result of a discrepancy between burden and endurance of the structure and/or tissues. Somatic dysfunctions precede functional diseases and are the basis thereof.

Discussion

In order to establish manual medicine in academic medicine, an accepted definition of functional diseases as diagnostic and therapeutic target is essential. Specific primary and secondary somatic dysfunctions are the cause for functional diseases and should therefore be diagnosed and treated. Other factors can also influence functional diseases and play an important role in their chronification. For chronic functional diseases, a multimodal interdisciplinary diagnosis is essential for the therapeutic strategy.

     

Wirksamkeit klassischer Massagetherapie bei chronischen Rückenschmerzen und Funktionsstörungen im Bewegungssystem

Manuelle Medizin - Klassische Massagetherapie (KMT) ist laut Physiotherapie-Ausbildungs- und Prüfungsverordnung Basis diagnostischer Tastfähigkeit zur Beurteilung von...     

Dreiwöchige stationäre multimodale Schmerztherapie bei Kindern und Jugendlichen mit chronischen Schmerzen

OBJECTIVE: In children and adolescents we investigated the impact of a 3-week inpatient multimodal pain therapy on subjective burden of life, pain intensity, and number of days off from school 3, 6, or 12 months later. METHODS: At the beginning of therapy (inpatient setting) and 3, 6, and 12 months thereafter (outpatient setting) we collected the respective data using standardized questionnaires. For statistical analysis we used Wilcoxon's signed rank test. A p <0.05 was regarded as statistically significant. RESULTS: A total of 72 patients aged 7.5-18.2 years suffering daily pain entered the study, most of them being diagnosed with somatoform pain disease. After 3, 6, and 12 months, 65, 27, and 30 patients could be reevaluated. Mean pain intensity of the week before data acquisition was significantly less than at the beginning (2.9, 2.3, and 2.9 vs 6.3) as was the mean number of days off from school due to pain during the 4-week period before each day of data acquisition (1.8, 1.5, and 1.4 vs 9.2). Mean subjective burden of life was significantly less than at the beginning (24.5, 22.0, and 25.8 vs 37.8). CONCLUSION: Outpatient multimodal pain therapy has a sustained impact on children and adolescents suffering from chronic pain.     

Schmerzverarbeitung bei Borderline-Persönlichkeitsstörung, Fibromyalgie und Posttraumatischer Belastungsstörung

The authors review relevant experimental studies on pain perception and processing in psychiatric disorders with traumatic stress as an etiological factor. In borderline personality disorder, post-traumatic stress disorder, and fibromyalgia neurophysiological and neuropsychological patterns of pain processing appear to be different. Experimental studies in borderline patients show a desensitization of pain thresholds whereas patients with fibromyalgia show an opposite pattern, which could be explained by a central augmentation of pain processing. Furthermore, the authors outline methods to assess pain perception (peripheral and central) and describe the neurobiological mechanisms of pain processing, particularly the distinction between the sensory-discriminative lateral system and the affective-motivational medial system. Finally, suggestions for further research and implications for therapy are proposed.