[Pain prevention in the primary care setting : Facts for resident physicians]

Based on health insurance data, approximately 37.4 million patients (46%) in Germany are diagnosed with "pain". The prevalence of patients with debilitating chronic pain is around 7.3%. From the health care perspective, and given the high socioeconomic relevance of chronic pain, effective preventive measures represent useful therapeutic approaches. In the context of pain medicine, primary prevention aims to avoid acute pain. Secondary prevention is targeted at preventing acute pain from turning into chronic pain. Tertiary prevention comprises measures to diminish pain-associated disability and impairment to everyday life. Finally, quaternary prevention focuses on avoiding medically non-indicated or unhelpful medical interventions. In addition to general approaches of pain prevention, such as detecting and treating of chronification factors (yellow, black and blue flags), the present article also describes educational and disease-specific approaches in musculoskeletal and neuropathic pain syndromes as well as headaches.

[Pain therapy care in Germany-Do patients receiving day care differ from those receiving outpatient or inpatient care at the start of treatment? : A further evaluation based on the KEDOQ-pain data set]

The direct comparison of day care pain patients with patients from other treatment sectors with respect to sociodemographic, pain-related and psychological characteristics has not yet been the subject of systematic analyses. The project core documentation and quality assurance in pain therapy (KEDOQ-pain) of the German Pain Society (Deutsche Schmerzgesellschaft e.V.) makes this comparison possible. This second analysis of the available KEDOQ data was intended to show how patients receiving day care treatment can be characterized using the core data set and whether and to what extent they differ from patients receiving outpatient or inpatient treatment. This is a continuation of the first publication, which showed remarkably small differences between outpatients and inpatients but did not include day care patients.The KEDOQ-pain data from 25 centers with a total of 8953 patients were evaluated. Patients had completed the German pain questionnaire (DSF) between January 2012 and March 2017 and received day care (n = 1264), outpatient (n = 4082) or inpatient (n = 3607) pain therapy treatment. Sociodemographic, pain-related and psychometric data of the DSF reported by patients were evaluated as well as physician information on the pain chronification stage and pain localization. The evaluation was descriptive and compared groups using univariate and multivariate procedures.Day care treated patients were significantly younger, had a higher level of education, were more frequently employed, reported higher impairment values and showed a higher severity index according to von Korff than inpatients and outpatients treated for pain. In addition, they described a shorter pain duration as well as worse habitual well-being (Marburg questionnaire on habitual well-being, MFHW). These predictors explained roughly half of the variance in the prediction of the day care treatment setting. The comparison of outpatients and inpatients showed significant group differences for some variables; however, the effects were very small.The evaluations suggest that pain therapy day care facilities treat a special group of pain patients that significantly differ from patients in other treatment sectors. Cautious conclusions are drawn regarding the systematic allocation of patients to care appropriate to their treatment needs.

[Implementation of interdisciplinary multimodal pain therapy according to OPS 8‑918 : Recommendations of the ad hoc commission for interdisciplinary multimodal pain therapy of the German Pain Association]

With the implementation of the German diagnosis-related groups (DRG) reimbursement system in hospitals, interdisciplinary multimodal pain therapy was incorporated into the associated catalogue of procedures (OPS 8‑918). Yet, the presented criteria describing the procedure of interdisciplinary multimodal pain therapy are neither precise nor unambiguous. This has led to discrepancies in the interpretation regarding the handling of the procedure-making it difficult for medical services of health insurance companies to evaluate the accordance between the delivered therapy and the required criteria. Since the number of pain units has increased in recent years, the number of examinations by the medical service of health insurance companies has increased. This article, published by the ad hoc commission for interdisciplinary multimodal pain therapy of the German Pain Association, provides specific recommendations for correct implementation of interdisciplinary multimodal pain therapy in routine care. The aim is to achieve a maximum level of accordance between health care providers and the requirements of the medical examiners from health insurance companies. More extensive criteria regarding interdisciplinary multimodal pain treatment in an in-patient setting, especially for patients with chronic and complex pain, are obviously needed. Thus, the authors further discuss specific aspects towards further development of the OPS-code. However, the application of the OPS-code still leaves room regarding treatment intensity and process quality. Therefore, the delivery of pain management in sufficient quantity and quality still remains the responsibility of each health care provider.

[Pain therapy in Germany - what is the difference between initial outpatient and inpatient treatment? : Assessment based on the KEDOQ pain dataset]

A comparison of chronic pain patients in outpatient and inpatient treatment settings regarding pain-related and psychological characteristics, has not yet been systematically analyzed. The core documentation and quality assurance in pain therapy (KEDOQ-Schmerz) is a quality assurance system for documentation and quality management of pain therapy in different treatment settings. The system was initiated by the German Pain Society. We used KEDOQ-Schmerz data to describe differences between patients being treated in outpatient and inpatient settings with respect to social, pain-related and psychological factors. In total, the set of KEDOQ-Schmerz data analyzed included information from 4705 patients (from 13 clinics) collected between January 2012 and April 2016. Patients received either outpatient (n = 2682) or inpatient (n = 2023) treatment. The data analyzed comprised sociodemographic, pain-related and psychological data collected through the German Pain Questionnaire (DSF) at the beginning of treatment as well as information about pain chronification and pain localization provided by practitioners. The statistical analysis was carried out by descriptive and comparative data analysis using univariate and multivariate statistical methods. Patients with inpatient treatment were significantly older, more often female and more often had multiple pain localizations. They described stronger pain intensity and more frequently had a higher Mainz Pain Staging System (MPSS) score of pain chronification. They described a significantly poorer physical and mental health-related quality of life in the short form (SF-12) health survey, had significantly higher depression, anxiety and stress values (DASS) and a poorer habitual well-being in the Marburg questionnaire on habitual well-being (MFHW). Significant group differences had only small effect sizes. Even though most predictors for the inpatient treatment setting in multivariate analysis were significant, in total they explained less than 5% of the variance. The results indicate that pain therapy in specialized pain settings more and more has to manage patients with higher pain chronification, higher pain-related stress and previous therapy experience. The differences in patient characteristics between treatment settings are mostly clinically unimportant. Differences in clinical features do not declare the allocation to one treatment setting or the other.

[Acute inpatient multimodal pain therapy and rehabilitation: Framework conditions, tasks and differentiated patient allocation]

Multimodal pain treatment programs are widely accepted as the medical treatment standard in the management of patients with chronic pain syndromes. The concepts and treatment strategies are based on the biopsychosocial model of pain and programs for early restoration of function. Although this concept is primarily implemented in the curative field, i.e. in hospitals for the treatment of patients with chronic pain diseases, modified programs based on the International Classification of Functioning (ICF) can now also be found in rehabilitation clinics. Despite the assumed similarities, significant differences in, for example the aims of the therapy and relevant structural and process variables have to be kept in mind when allocating patients to a program as provided by a hospital or a rehabilitation clinic. The aim of this article is to present the framework structures of both treatment levels with respect to the implementation of multimodal pain therapy programs and to elucidate the differential diagnostic approach to the indications.

[Multidisciplinary assessment for multimodal pain therapy. Indications and range of performance]

According to evidence-based German national guidelines for non-specific low back pain, a broad multidisciplinary assessment is indicated after persisting pain experience of 6 weeks in order to check the indications for an multi- and interdisciplinary pain therapy program. In this paper the necessary topics, the content and the disciplines involved as well as the extent of the multidisciplinary assessment are described as developed by the ad hoc commission on multimodal pain therapy of the German Pain Society.

[Structure and process quality of multimodal pain therapy. Results of a survey of pain therapy clinics]

Multimodal therapy has demonstrated good clinical effectiveness in the treatment of chronic pain syndromes. However, within the German health system a comprehensive and nationwide access to multimodal therapy is not available and further improvement is therefore necessary. In order to analyze the current status of multimodal therapy and specifically its structural and procedural requirements and qualities, a survey was carried out in 37 pain clinics with established multimodal treatment programs. An anonymous questionnaire was used for data collection. Results demonstrated that a substantial accordance was found between all pain clinics concerning requirements for space, facilities and staff. Structured multidisciplinary assessments were carried out by all pain clinics even though the amount of time allocated for this varied widely. The main focus of multimodal therapy in all facilities was based on a common philosophy with a cognitive-behavioral approach to reduce patient helplessness and avoidance behavior and to increase physical and psychosocial activities as well as to strengthen self-efficacy. Some differences in the ways and means to achieve these goals could be demonstrated in the various programs.

Healthcare utilization of back pain patients: results of a claims data analysis

OBJECTIVES

The high life-time prevalence of chronic back pain (25-30% according to surveys in small samples) suggests that it may be a major source of healthcare cost and that prevention of chronic back pain may be both ethically and economically recommendable. To obtain valid economic data on the cost of back pain in Germany, a retrospective claims data analysis was performed.

METHODS

Using data from 2006 of 5.2 million beneficiaries of a German statutory health insurance fund (DAK Unternehmen Leben) covering ~7% of the German population, mean value analyses report on key healthcare utilization figures from a sickness funds? perspective. In contrast to other studies, cost data are primary data and not extrapolated, but clinical characteristics include surrogate markers as no clinical case descriptions were available.

RESULTS

Based on previously investigated diagnosis patterns three types of back pain could be identified: (other) specific back pain (n=211,216), pain due to spinal disk disease (n=195,712), and non-specific back pain (n=534,272). Of all back pain patients, 25.8% were identified as at risk to develop chronic pain, where only 2.6% were detected as patients with chronic back pain. Mean resource utilization and related healthcare costs were significantly higher for beneficiaries with indicators for chronic back pain than for beneficiaries with only risk factors for developing chronic back pain. This especially holds for outpatient analgesic prescriptions (p<0.05), for in-hospital multimodal pain therapy (p<0.05), for in-hospital care in general (p<0.05), as well as for direct cost of care (p<0.05).

CONCLUSION

The results show the potential that could be made accessible by an early detection of back pain patients who bear a risk of pain becoming chronic, both in terms of quality-of-life as well as in financial terms.

[Multimodal pain therapy: principles and indications]

Multimodal pain therapy describes an integrated multidisciplinary treatment in small groups with a closely coordinated therapeutical approach. Somatic and psychotherapeutic procedures cooperate with physical and psychological training programs. For chronic pain syndromes with complex somatic, psychological and social consequences, a therapeutic intensity of at least 100 hours is recommended. Under these conditions multimodal pain therapy has proven to be more effective than other kinds of treatment. If monodisciplinary and/or outpatient therapies fail, health insurance holders have a legitimate claim to this form of therapy.Medical indications are given for patients with chronic pain syndromes, but also if there is an elevated risk of chronic pain in the early stadium of the disease and aiming at delaying the process of chronification. Relative contraindications are a lack of motivation for behavioural change, severe mental disorders or psychopathologies and addiction problems. The availability of multimodal pain treatment centers in Germany is currently insufficient.

[The FADI score--a possibility for the quantified differential diagnosis of discogenic pain]

AIM

Chronic, non-radicular low-back pain has varying reasons. The main causes are a zygoapophysial joint syndrome, discogenic pain, especially the rupture of the inner disc, the IS joint syndrome as well as a myofascial syndrome. Especially the differentiation between zygoapophysial joint pain and discogenic pain often proves to be difficult in the clinical routine. In the literature, different criteria can be found concerning the distinction of zygoapophysial joint pain and discogenic pain. Clinical criteria, criteria of imaging as well as intensive diagnostics are described. So far there is a lack of a summarizing evaluation of these aspects.

METHOD

The FADI score uses clinical criteria with combinations of motion, consisting of rotation, side inclination, anteflexion and pressure-sensitive spots, imaging aspects and the invasive diagnostics by means of selective blockades of zygoapophysial joints and discography or rather disc stimulation. The examination results are summed up and judged as to their relevance as well as validity through our score.

RESULTS

First of all the relevance of the single aspects was judged in a primary test with 30 patients. The diagnostic block and the clinical criteria for the zygoapophysial joint syndrome as well as discography and MRI for discogenic pain had the best results. Afterwards the score was tested in the clinical area with 56 patients and showed its value under clinical conditions.

CONCLUSION

Especially when dealing with patients suffering from chronic back pain, the score serves to simplify the choice of a further therapy, including invasive procedures, or rather to avoid unnecessary major surgery at the spine.

[Ultrasound diagnosis of the meniscus]

As a supplement to clinical findings, sonographic examination of the meniscus is an easily available, noninvasive imaging technique that can be used to optimize preoperative diagnosis and check the indication for arthroscopy. Careful consideration of the technical requirements and systematic performance of the dynamic examination should lead to further improvement of the examination results and to growing clinical significance in the future.

[A structured pain interview for geriatric patients]

BACKGROUND

In old age, assessment of pain often is hampered by sensory and cognitive deficits that do not allow the patients to fill in standardized questionnaires without help from significant others. Therefore, as an alternative, we developed a structured pain interview, and examined its properties and acceptance in a sample of geriatric patients with pain.

METHODS

The interview covers site of pain, intensity of pain, its duration and persistency, pain related disability and, finally, emotional and cognitive variables. In addition, the interviewer addresses significant others to get information about medication, previous treatment, and residence, and administers the Mini-Mental-State-Examination (MMSE). The analysis includes 128 patients of pain centers older than 74 years, of whom 80% are female.

RESULTS

Forty percent of the subjects score below the critical MMSE value < or =23 indicative of cognitive impairment. These patients are responsible for 36 out of a total of 39 missing values. A significant increase of missing values is observed in patients with a MMSE score below 10. Cognitive impairment goes along with greater functional and social disability. On the other hand, cognitive impairment is unrelated to localization, intensity, and duration of pain. The memory item of the MMSE can be used as a screening tool for cognitive impairment. Patients, who are unable to recall any of the three objects, comprise 80% of the total of missing values and demonstrate a low MMSE score.

CONCLUSION

As long as geriatric patients are able to communicate verbally, they are most likely to profit from the structured pain interview in spite of existing cognitive impairment. A MMSE score <10 indicates that the interpretation of the data obtained may be difficult, especially due to a high frequency of missing values.

Reactivation of a tuberculous coxitis due to loosening of a total hip endoprosthesis

A 45-year-old woman who suffered from juvenile tuberculous coxitis at the age of 4 is presented. Her hip joint replacement lasted for 18 years and then needed replacing. Intraoperatively removed caseous soft tissue and an opalescent secretion histologically resembled a tuberculous focus, and bacteriological culture grew a Mycobacterium tuberculosis strain. Four months after the replacement, the patient suffered from a tuberculosis-induced septic loosening of the newly replaced hip joint endoprosthesis. The tuberculosis relapse was probably due to aseptic loosening of the first hip joint endoprosthesis.

[Increased incidence of developmental hip dysplasia in hypertrophic newborn infants]

"Lack of space" in utero is considered to be a major factor in the aetiology of the congenital dislocation of the hip. This study tries to answer the question whether hypertrophy of a newborn has to be regarded as a risk factor on the basis of the principle mentioned above. The results of postnatal clinical and sonographical examination performed on 98 large-for-gestational-age (LGA-) newborn were compared to those performed on 310 newborn children during a non selective screening program. Among the LGA-newborn pathological hip joints were found more often mainly female LGA-newborn infants were affected. It seemed that the birth weight did not correlate to the extent of the retardation of the hip joint development. It was again confirmed that the restriction to only clinical diagnostic procedures in the neonatal period is not effective in the early diagnosis of the malformation. Hypertrophy of a newborn has to be considered as a risk factor behind the development of congenital dislocation of the hip. It is recommended to examine all LGA-newborn infants post partum by clinical and most importantly also by sonographical means to recognize a retardation of hip joint development.

[Current developments in ultrasonography of the meniscus]

Sonography of the meniscus is a new diagnostic method, the instructive value and clinical relevance of which are subject to controversy. Sonographic assessment of the meniscus requires the use of focusing that can cope with the different anatomical conditions of the individual parts of the meniscus and can largely eliminate artifacts by means of wide sound-wave propagation. The dynamic examination technique allows the identification of both longitudinal and flap tears, which are relatively easy to diagnose, and of tear formations that are harder to visualize, such as horizontal and transversal tears. A sonographic criterion of a tear is the detection of a clearly visible, strong-signal double or single-stroke reflection pattern that can be traced in several section planes. While sonographic examination allows location of the tear, definite conclusions as to the shape of the tear are not possible on the basis of the echo pattern. In the literature, the statistical results, depending on the patient group and technical equipment, vary between 76% and 100% for sensitivity and between 50% and 97% for specificity, 74% and 93% for accuracy and between 61% and 95% for the positive prediction value. Sonographic examination of the meniscus is an easily available, noninvasive imaging technique that, as a supplement to clinical findings, can be used to optimize preoperative diagnosis and to check the indication for arthroscopy. Careful consideration of the technical requirements and systematic performance of the dynamic examination should lead to further improvement in the examination results and to growing clinical significance in the future.

A new holder and surface MRI coil for the examination of the newborn infant hip

A special holder was developed for examination of the infant hip joint using MRI. This holder allows the infant hip joint to be examined both in a neutral position and in various defined functional positions. A special integrated surface coil, also developed for this purpose, provides the high spatial resolution required for assessment of the fine joint structures. Thirty infants were examined and the new device has proved useful in advanced hip dysplasia, therapy-resistant subluxation and luxation, and for operative therapy planning (reconstruction of the acetabular roof, redirectional osteotomies). Interpretation errors due to misprojection can be eliminated to a large extent since the holder allows standardized and reproducible positioning.

[Immune competence of human tissue lymphocytes in contact with loosened hip joint prostheses. On the topic of cellular or humoral rejection reaction as the mechanism of loosening]

In several investigations rejections were accused of being a possible cause for the loosening of hip endoprostheses. Using immunocytochemical techniques we studied the number and type of lymphocytes in the tissue adjacent to loosened hip endoprostheses. Tissue samples were taken from 18 patients being reoperated for a loosened endoprostheses. Impressive lymphocyte infiltrates were found in 4 of 18 patients (22%). These infiltrates only consisted of T-cells. In the other samples only few lymphocytes were detected belonging to T- and B-lymphocyte population, respectively. In our patients T-cell mediated rejections were of minor importance for the loosening of total hip replacement. B-cell accumulations were detected in none of the samples.

[Dynamic examination technique in meniscus sonography]

The aim of this study was to introduce an improved dynamic examination technique for sonographic assessment of the menisci, a technique that takes into account the special anatomy and function of the knee joint. The dynamic examination technique was used together with a 7.5 mhz sector transducer fitted with a water or PVC pad attachment when the area around the anterior horn and the pars intermedia was being scanned. Misinterpretation as a result of confusing reflections from a tear with the Hoffa fatty pad, popliteal tendon or popliteal groove can be largely avoided owing to the better sonoanatomic imaging and orientation. Diagnosing lesions of the meniscus from echogenic torn surfaces has also become easier thanks to dynamic examination. 60 patients with, for the most part, chronic knee-joint complaints were selected. A comparison of sonographic and arthroscopic findings demonstrated that large percentages of tears in the meniscus can be detected (76.7%) or ruled out (90.0%), and that recent longitudinal tears, flap and non-luxated bucket-handle tears can be considered to be "ideal" tear shapes. Because of its high specificity, sonography of the meniscus presents itself as a suitable method when lesions have to be ruled out, especially in recent knee injuries where clinical findings are unclear. On the other hand, if there are sure indications of a tear, sonography of the meniscus makes it possible to introduce therapeutic measures immediately and thereby to avoid any possible secondary damage.

[Experimental studies of sonography of the meniscus]

The aim of this examination was to recognize and, if possible, avoid the origin of artifact images in sonograms caused anatomically and by the physics of ultrasound. Experimental investigations were carried out in a waterbath on models of knee joints using Schlierenoptics and on specimens from corpse knees. When a sector transducer was used, the artifact images that originated in the joint cavity appeared outside the cavity on the sonogram so that there were no danger of mistaking them for reflected images of tears in lesions of the meniscus. In sonography, the surfaces of tears reflect a strong signal, but diagnosis depends on the position of the edges of the tears to the direction of the ultrasonic waves, which means to get a reliable record of tears of the meniscus is only possible by means of a dynamic examination technique.

MR-anatomy of infants hip: comparison to anatomical preparations

The correlation between anatomical preparations and MRI images of the most important structures of newborn hips in coronal and axial orientation was performed in 18 post mortem babies. T1-weighted images present a good differentiation between cartilage, bone, ligaments and surrounding soft tissues. Coronal images give the best opportunity to study the clinically important structures of the roof of acetabulum including the labrum and the ground of the acetabulum. The latter is shown in a more detailed way by MRI than by sonography. Axial images allow additional examinations of the ventral and dorsal parts of the joint. By using both coronal and axial images the exact determination of the centering of the femur head in the hip joint is possible.

Influence of bone and soft-tissue operations on serum concentrations of growth hormone, somatomedin C and alkaline phosphatase

After animal experiments suggested there was an interaction between growth hormone and bone healing, our aim in this paper was to ascertain whether there were any changes or possible interaction between the serum level of growth hormone, somatomedin C and alkaline phosphatase while a fractured bone was healing. To this end, the serum concentrations of growth hormone, somatomedin C, alkaline phosphatase and calcium were ascertained both pre- and post-operatively in two groups of patients--one with bone operations, the other with soft-tissue operations--and the results were compared. Comparing the groups, we found that after bone operations there was no increase in the serum level of growth hormone, nor of somatomedin C. An increase would have implied that these two hormones are directly involved in bone regeneration. There was no change in the serum level of alkaline phosphatase or calcium after either bone or soft-tissue operations.

Treatment of an old infection in a total hip replacement with an interim spacer prosthesis

When treating a septic hip-joint prosthesis with bone loss of the proximal femur secondary to osteomyelitis, we implanted a specially designed prosthesis to act as a local antibiotic and spacer between the acetabulum and femur until the infection abated. Arthroplasty could then be carried out with no trouble and there was no recurrence of infection.

Current evaluation of sonography of the meniscus. Results of a comparative study of sonographic and arthroscopic findings

Sonography of the knee has gained in significance in the diagnosis of the meniscus; experimental and clinical studies have demonstrated that the normal and pathological anatomy of the meniscus can be visualized on a sonogram. The aim of this comparative investigation is to evaluate sonographic lesion diagnosis in comparison with arthroscopic findings, using a standardized examination method. Two hundred and six knee joints were first scanned sonographically using a 7.5 MHz sector transducer. The examining doctor had neither anamnestic nor clinical information in advance. On the following day, the joints were examined arthroscopically, without the findings of the day before being available to the examiner. When the findings were compared, the sensitivity of sonographic diagnosis of lesions was found to be 82.2% and its specificity 87.6%. The patients were of varying ages and had varying anamneses. The results show that sonography of the meniscus is a valuable diagnostic help when the knee-joint symptoms are not clear, given that the correct technical equipment and sufficient experience with this form of examination are at hand. The advantage of sonography is that, in contrast to arthroscopy, it is noninvasive and easily available.

[Treatment of infected total hip endoprostheses]

In total hip arthroplasty the most serious complication besides aseptic loosening is infection. The results observed in 42 cases of infected hip arthroplasties are presented. In contrast to early superficial infection, deep infection following total hip replacement is difficult to treat. Depending on the general condition of the patient, a well-defined, adequate treatment is required. In patients at vital risk the provocation of a permanent fistula can be recommended as an alternative method in preference to revision arthroplasty.

[Real-time sonography of the infant hip joint in the early diagnosis of congenital hip dysplasia]

The ultrasonic examination of infant hip joint means a great advantage in early diagnosis of congenital hip dysplasia. The sonographic type classification by Graf enables the experienced examiner to make up a differentiated diagnostic-therapeutic concept as early as possible. Therapeutic omissions just as well as exaggerated therapeutic measures can be avoided. Consequently the prognosis of hip joint dysplasia is considerably improved by ultrasonic examination of new-born hip joints.