[Need for Action and Research in Psychosomatic and Orthopaedic Rehabilitation from the Point of View of Rehabilitants and Individuals who work in Rehabilitative Care]

PURPOSE

The aim of this study was to assess the need for practical action and research in psychosomatic and orthopaedic rehabilitation from the perspective of rehabilitants and individuals who work in rehabilitative care.

METHODS

The project was divided into an identification and a prioritization phase. In the identification phase, 3872 former rehabilitants, 235 employees from three rehabilitation clinics and 31 employees of the German Pension Insurance Oldenburg-Bremen (DRV OL-HB) were invited to participate in a written survey. The participants were asked to name relevant needs for action and research for psychosomatic and orthopaedic rehabilitation. The answers were evaluated qualitatively using an inductively developed coding system. Practical fields of action and research questions were formulated from the categories of the coding system. In the prioritization phase, the identified needs were ranked. For this purpose, 32 rehabilitants were invited to a prioritization workshop and 152 rehabilitants, 239 clinic employees and 37 employees of the DRV OL-HB to a two-round written Delphi survey. The resulting prioritized lists from both methods were combined into a top 10 list.

RESULTS

In the identification phase, 217 rehabilitants, 32 clinic employees and 13 employees of the DRV OL-HB participated in the survey, in the prioritization phase, 75 rehabilitants, 33 clinic employees and 8 employees of the DRV OL-HB in both survey rounds of the Delphi survey, and 11 rehabilitants in the prioritization workshop. A need for practical action primarily in the implementation of holistic and individual rehabilitation, in quality assurance and in the education and participation of rehabilitants was identified, as also a need for research primarily on access to rehabilitation, structures in the rehabilitation setting (e. g., inter-agency cooperation), the design of rehabilitative interventions (more individualized, more suitable for everyday life), and the motivation of rehabilitants.

CONCLUSION

The identified needs for action and research include many topics that have already been identified as problems in previous research projects and by various actors in rehabilitation. In the future, there needs to be increased focus on the development of strategies for dealing with and solving the identified needs, as well as on the implementation of these strategies.

Gender effects on outcomes of psychosomatic rehabilitation are reduced

OBJECTIVE

The study examined whether psychiatric/psychosomatic rehabilitation continues to have a better course of treatment for women than men.

METHODS

We compared the course of global symptom severity, health-related quality of life and functioning between admission and discharge in patients (848 men, 1412 women) at an Austrian psychiatric/psychosomatic rehabilitation clinic.

RESULTS

Gender-specific differences in the course of treatment were all too small to be clinically relevant. The differences were smallest in the middle-aged cohort. However, at the time of admission, women reported a slightly higher symptom burden.

CONCLUSION

Overall, the results show a gender-fair effectiveness of the rehabilitation. The new findings could be explained by changes in living conditions, gender roles, or better treatment methods.

``The pain isn't as disabling as it used to be'': How can the patient experience empowerment instead of vulnerability in the consultation?

Aim: This study explores how doctors can help patients transform vulnerability into strength, instead of increasing a feeling of disempowerment. Methods: The authors analysed their findings from four previously written articles based on qualitative interviews with 10 women with chronic pain, comparing the reported negative consultation experiences with the beneficial effects of good treatment experiences, in order to identify potentials for change. Results: Altering the way in which the women are encountered may empower and help them deal with a painful life. Doctors can challenge stereotyped macro-structures of women's ``unexplained'' pain as hysteria by admitting the shortcomings of medical knowledge. The blame is then put on the medical discipline instead of the individual patient who presents bodily symptoms or reveals help-seeking behaviour that does not fit with biomedical expectations of what illness is and how it should be performed. Thus, the vulnerable position described by the patients can be converted or transformed into strength or resources in spaces that promote empowerment through recognition. Conclusion: Although doctors may feel helpless or puzzled in the consultation, they must take the responsibility for turning the consultation into a space for empowerment of the patient.

The first encounter with Norwegian psychomotor physiotherapy: patients' experiences, a basis for knowledge

Aims: The intention of this study was to elucidate patients' experiences of the examination of the body given in Norwegian Psychomotor Physiotherapy. Methods: A qualitative approach was used, based on interviews with nine women and one man aged between 41 and 65 years. The data were analysed with the aid of grounded theory, using the first two steps: open and axial coding. Results: Three categories were identified from the patients' experiences. The first category "The Situation before Treatment'', emerged from the subcategories "Prejudice concerning the prefix `psycho''', "Difficulties in recognizing the body's information'', and "The body is ambiguous''. The second category, "Establishing the Relationship'', emerged from the subcategories "Getting to know the therapist as an empathic person'' and "Discovering professional skills''. The third category, "Examination is Interaction'', emerged from the subcategories "Dialogues - room for reflection'', "Undress, the feeling of disclosure'', and "Personal boundaries - good to be seen''. These three categories emphasize the importance of cooperation between the physiotherapist and the patient in exploring the social and emotional context in order to understand the meaning of the body's symptoms. There must be no doubt about the skill and competence of the therapists, including their insight, personal responsibility, engagement, attentiveness, and awareness. Conclusions: Our material reflects the great impact the body examination had on the informants. Examination requires mutual interpretation. The patients' knowledge represents a significant potential for understanding of their own situation.

Physical treatment of functional neurologic disorders

Physical interventions are widely considered an important part of treatment of functional neurologic disorders (FNDs). The evidence base for physical interventions has been limited to a collection of case series, but the recent publication of several large cohort studies and a randomized controlled trial have provided stronger evidence to support its use. While the evidence for efficacy appears to be promising, details on how this should be delivered remain limited, perhaps due to the dominance of psychologically focused etiologic models. A move towards understanding how the symptoms of FND are generated on a neurobiologic level has resulted in an expansion of pathophysiologic models providing a clearer rationale for physical treatment. In this context, the motor symptoms of FND can be considered as learnt patterns of movement, driven by attention and belief. Physical treatment aims to retrain movement by redirecting attention and addressing unhelpful illness beliefs and behaviors. The patient's problems should be considered in a broad biopsychosocial framework where symptom-predisposing, precipitating, and perpetuating factors can be addressed within a multidisciplinary environment as a gold standard. Further research is required to refine interventions and create evidence-based treatment guidelines.

[Psychosomatic issues in the rehabilitation of motor organs]

The relation between bodily health and mental health has been observed since ancien Times. Ancient teachers of the art of medicine advised to treat a person not an illness. Facination with the discoveries concerning the cell was the reason why investigation of somatic illnesses concentrated more and more on exploring physiology , ignoring mental aspects. Psychoanalysis, on the other hand considered mental sphere as the source of all illnesses. Although psychoanalitical approach is still controversial psychologists and doctors are still trying to find relations between personality traits and illnesses. Investigating psychological factors in etiology of motor organs disorders is not common but significant for the treatment. The paper presents disorders of mental adjustment which seem particularly important in rehabilitation of motor organs. They are illustrated by descriptions of case studies from clinical practice.

Themes of coping in the spectrum of domestic violence abuse: a review of the literature

Women's coping experiences in the spectrum of domestic violence abuse are complex and multifaceted. The spectrum stages of abuse include when a woman is in, out, or returning to the abuse situation. In this article the author discusses the obstacles with which women cope and the service delivery initiatives to better serve women. The themes of women's coping in the spectrum of abuse for this research review include psycho-physiological, economic, education, family, and childcare factors. Service practitioners must fully recognize the factors with which women of abuse cope. Included are suggestions for service professionals aiding women to improve services as women utilize multiple services simultaneously.

[Preparation for and care after medical rehabilitation using the example of psychosomatic rehabilitation]

For successful reintegration into working life after inpatient medical and psychosomatic rehabilitation, it is necessary that treatment efforts prior to inpatient rehabilitation treatment, during the medical care itself, and after rehabilitation are distributed appropriately. Ideally, in addition to adequate psychotherapeutic treatment by established therapists/doctors, preparation for the upcoming rehabilitation should concentrate on helping patients lose their fear and also to shed light upon the objectives of a psychosomatic rehabilitation with special emphasis on vocational rehabilitation. Shortly after psychosomatic rehabilitation, aftercare supports, in particular, the transfer of the rehabilitation results and reintegration into working life. However, only a fraction of the patients are reached by this aftercare offer. For rehabilitation, patients with special job problems, migrants, or long-term unemployed persons, case management is proposed, should aftercare not be sufficient.

A behaviorist perspective

Chronic pain is a sensory experience that produces suffering and functional impairment and is the result of both sensory input as well as secondary adaptation of the nervous system. The sensitization of the nervous system to pain is influenced by physical activity (or inactivity) and medication exposure. Medication taking and physical activity are behaviors that are increased or decreased by positive and negative reinforcement. Patients often have comorbid psychiatric conditions at presentation, including addictions, mood disorders, personality vulnerabilities and life circumstances that amplify their disability and impede their recovery. Behavioral conditioning contributes to chronic pain disorders in the form of both classical (Pavlov) and operant (Skinner) conditioning that increases the experience of pain, the liability to ongoing injury, the central amplification of pain, the use of reinforcing medications such as opiates and benzodiazepines, and behaviors associated with disability. The term 'abnormal illness behavior' has been used to describe behaviors that are associated with illness but are not explained physiologically. Behavioral conditioning often amplifies these abnormal behaviors in patients with chronic pain. Addiction can also be seen as a behavior that is reinforced and conditioned. The same factors that amplify abnormal illness behaviors also increase the liability to addiction. Psychiatric comorbidities also complicate and amplify abnormal illness behaviors and addictive behaviors and further contribute to the disability of chronic pain patients. Model interventions that reinforce healthy behaviors and extinguish illness behaviors are effective in patients with addictions and chronic pain. Maladaptive behaviors including addictive behaviors can be used as targets for classical and operant conditioning techniques, and these techniques are demonstrably effective in patients with chronic pain and addictions.

[Shared decision-making and individualized goal setting - a pilot trial using PRISM (Pictorial Representation of Illness and Self Measure) in psychiatric inpatients]

BACKGROUND

Although there is much talk about shared decision making and individualized goal setting, there is a lack of knowledge and knowhow in their realization in daily clinical practice. There is a lack in tools for easy applicable tools to ameliorate person-centred individualized goal setting processes.

METHOD

In three selected psychiatric inpatients the semistructured, theory driven use of PRISM (Pictorial Representation of Illness and Self Measure) in patients with complex psychiatric problems is presented and discussed.

RESULTS

PRISM sustains a person-centred individualized process of goal setting and treatment and reinforces the active participation of patients. The process of visualisation and synchronous documentation is validated positively by patients and clinicians. The visual goal setting requires 30 to 45 minutes.

CONCLUSIONS

In patients with complex psychiatric illness PRISM was used successfully to ameliorate individual goal setting. Specific effects of PRISM-visualisation are actually evaluated in a randomized controlled trial.

A systematic review of neurobiological and clinical features of mindfulness meditations

BACKGROUND

Mindfulness meditation (MM) practices constitute an important group of meditative practices that have received growing attention. The aim of the present paper was to systematically review current evidence on the neurobiological changes and clinical benefits related to MM practice in psychiatric disorders, in physical illnesses and in healthy subjects.

METHOD

A literature search was undertaken using Medline, ISI Web of Knowledge, the Cochrane collaboration database and references of retrieved articles. Controlled and cross-sectional studies with controls published in English up to November 2008 were included.

RESULTS

Electroencephalographic (EEG) studies have revealed a significant increase in alpha and theta activity during meditation. Neuroimaging studies showed that MM practice activates the prefrontal cortex (PFC) and the anterior cingulate cortex (ACC) and that long-term meditation practice is associated with an enhancement of cerebral areas related to attention. From a clinical viewpoint, Mindfulness-Based Stress Reduction (MBSR) has shown efficacy for many psychiatric and physical conditions and also for healthy subjects, Mindfulness-Based Cognitive Therapy (MBCT) is mainly efficacious in reducing relapses of depression in patients with three or more episodes, Zen meditation significantly reduces blood pressure and Vipassana meditation shows efficacy in reducing alcohol and substance abuse in prisoners. However, given the low-quality designs of current studies it is difficult to establish whether clinical outcomes are due to specific or non-specific effects of MM.

DISCUSSION

Despite encouraging findings, several limitations affect current studies. Suggestions are given for future research based on better designed methodology and for future directions of investigation.

[Indication criteria for stationary psychosomatic treatment]

In consideration of the existing possibilities in Germany, the author discusses the indication criteria and the duration of stationary psychosomatic treatment. Aside from the general criteria for hospitalisation, the traditional bio-psycho-social model of illness is emphasized as an important basic principle, to include social factors in the indication criteria for stationary psychosomatic treatment. Adjacent, backgrounds for the decision between a regional and a regionally distant treatment are proposed.

[Psychotherapeutic and psychosocial approaches in bipolar disorder: a systematic literature review]

OBJECTIVE

Aim of this systematic review was critical presentation of psychosocial approaches in bipolar disorders with regard to their fundamentals and impact on the clinical course and outcome of the illness.

METHOD

PubMed, Medline, PsycINFO and Turkish databases between 1980 and 2009 were searched by using keywords "bipolar disorder" and "psychotherapy", "psychosocial approaches", "psychological intervention". Randomized controlled trials, reviews and meta analysis were included.

RESULTS

Fifty studies met the inclusion criteria where four types of interventions -psychoeducation, family focused, cognitive behavioral and interpersonal psychosocial rhythm therapy-were studied. Twenty two of 24 original research papers were randomized controlled trials, 23 were reviews and 3 were meta analysis. In almost all studies psychotherapeutic approach was applied as adjunctive to pharmacotherapy. Group psychoeducation was more effective in preventing manic relapses, whereas cognitive behavioral and family focused therapies showed efficacy in preventing depressive episodes. Additional benefits on such secondary outcomes as medication compliance, number and duration of hospitalizations, time to recurrence were reported. Effects on functionality and quality of life were assessed rarely, but reported to be beneficial. Cultural adaptation studies are scarce and needs exploration.

CONCLUSION

Psychosocial interventions adjunctive to pharmacotherapy in bipolar disorder seem to be effective in relapse prevention. Stage of illness where the therapy is initiated and the targeted episode for prevention varies between interventions. Future studies are needed to strengthen the place of psychosocial interventions in treatment guidelines and would contribute to narrow the gap between effectiveness of pharmacotherapy and functional improvement.

Reliability and validity of a standardized Mensendieck physiotherapy test (SMT)

A standardized test was developed to evaluate posture, movement, gait, sitting posture, and respiration of patients with psychosomatic disorders, based on the Mensendieck principles of observation and analysis of motor function. To validate the test and to make a comprehensive body examination of a defined group of patients, it was applied in a study of women with chronic pelvic pain (CPP, ICD10 F45.4). Fifteen women with CPP and 15 matched, healthy controls were examined. Test subjects were video recorded and scored by three experienced Mensendieck physical therapists, blinded with respect to the selection of subjects. Scores from 0 (for least functional movement) to 7 (optimal function) were assigned to each test person according to a test manual. High intraclass correlations (ICC1.1 [corrected] ranging from 0.82 to 0.97) were found among the testers. The standardized Mensendieck test (SMT) discriminated well between women with CPP and the controls (sensitivity 0.9, specificity 0.7, mean values). The CPP patients scored significantly lower than the controls in all subtests (p < 0.01). The largest difference in scores were found for gait (patients 2.70 +/- 0.11, vs. control, 5.60 +/- 0.09) and respiration (patients 2.88 +/- 0.14, vs. control, 5.63 +/- 0.10). The results indicate that, in the hands of experienced Mensendieck therapists, the SMT is a reliable tool, demonstrating a good discriminative validity. Furthermore, it may turn out to be a useful instrument in the evaluation of patients with somatoform disorders. It may also point toward a possible therapeutic treatment approach to patients with CPP.

[Cognitive training in rehabilitation: a program to treat mild cognitive impairment]

As part of a research project, a behavior therapy-oriented cognitive training program, designed to improve the cognitive ability of middle-aged employees (50 to 59 years), was implemented and evaluated. The goal of the training program was to analyze the cognitive, affective and behavior-related conditions of memory deficits in the workplace. The training focused on two topics: (1) development of new job tasks, (2) lack of time and deadline constraints. A total of 316 patients in the psychosomatic clinic of Bad Neustadt participated in the study. Those who showed cognitive impairments took part in the cognitive training program during the intervention phase. During the control phase, patients with cognitive impairments received no additional intervention. The neuropsychological screening was repeated with patients with cognitive impairments at discharge. The findings show that the objective and subjective memory performance of the participants improved significantly compared to that of the control group. At the 1-year follow-up, 84% of the participants reported that they could use the training strategies in their job.

Effects of health education for migrant females with psychosomatic complaints treated by general practitioners. A randomised controlled evaluation study

OBJECTIVE

The effectiveness of use of migrant health educators in the general practitioners' care for female migrants with psychosomatic problems was evaluated to contribute to the improvement of the care for these patients.

METHODS

A randomised controlled trial (RCT) design was used. A total of 104 patients (75%) agreed to take part in the intervention study. The patients were from Turkish and Moroccan immigrant groups living in The Netherlands. The intervention group received counselling and education from the migrant health educators as adjuncts to the GPs' care. Special attention was given to the patient's cultural background, supporting the communication between GP and patient. The control group received regular treatment from their GPs.

RESULTS

A significant improvement of perceived general health, psychological health and reported ability to cope with pain was observed among the intervention group. No effects were found for social support and the perceived burden of stressful life-events.

CONCLUSION

The patients' perceived health and coping abilities improved through the intervention as a whole. Not all outcome measures had been affected due to among others the diversity of physical and psychological complaints the patients suffered from, non-compliance and a perceived decrease of disability over time.

PRACTICE IMPLICATIONS

The intervention methods should be integrated in the patient care delivery for migrants in general practice. Further development of intervention methods to address the patients' social support is recommended.

Anxiety disorders and workplace-related anxieties

BACKGROUND

Workplace-related anxieties are often connected with sick leave. There are no established instruments which allow to assess this phenomenologically heterogeneous group of disorders.

METHOD

One hundred and thirty-two psychosomatic inpatients were interviewed with a standardized diagnostic interview in respect to mental illnesses, especially primary anxiety disorders, and in addition in respect to different work-related anxiety disorders.

RESULTS

Seventy-one percent of women and 54% of men complained about work-related anxiety. 20.5% of participants are suffering from work-related panic, 58% from work-related phobia, 34.1% from work-related social phobia, 39.4% from work-related generalized anxiety, and 1.5% from work-related PTSD. There is a moderate relation between mental disorders or primary anxiety disorders and work-related anxiety. Fourteen percent of the participants did only suffer from workplace-related anxiety and did not report any other anxiety disorder outside the workplace situation.

CONCLUSION

There are various types of workplace-related anxieties. They are partly independent clinical phenomena deserving special diagnostic and therapeutic attention.

Managing postacute hospital care: a case for biopsychosocial needs

OBJECTIVE

This study aimed to investigate whether, for an identical diagnosis, patients who were transferred to a postacute care (PAC) facility had a higher biopsychosocial complexity than patients who were discharged home.

METHODS

This prospective study employed group comparison that included 166 patients who were consecutively admitted to an acute care internal medicine ward for acute congestive heart failure, pneumonia or exacerbation of chronic obstructive pulmonary disease, and malaise or fall. Patients were evaluated within their first 48 h of stay. Biomedical, functional, quality of life, and case complexity data were collected. Factors associated with a transfer to the PAC facility were identified through logistic regression modeling.

RESULTS

Fifty-eight patients (34.9%) were transferred. In the multivariate analyses, case complexity score [per point: odds ratio (OR)=1.29; 95% CI=1.18-1.41] and nursing workload (OR=1.06; 95% CI=1.01-1.12) were associated with the transfer. At a cutoff point of > or =33, the case complexity score predicted transfer to the PAC facility with a sensitivity of 79% and a specificity of 84% (positive predictive value=73.0%; negative predictive value=88.4%) and correctly classified 83% of the cases.

CONCLUSIONS

Biomedical characteristics alone did not differentiate patients who were transferred versus those who were discharged home, nor did it predict PAC use. This was also true for specific severity scores of cardiac failure and pneumonia as well as for the comorbidity index. Psychosocial parameters were significantly associated to this process as well as a higher nursing workload.

Diagnosis and classification of pelvic girdle pain disorders, Part 2: illustration of the utility of a classification system via case studies

Pelvic girdle pain (PGP) disorders are complex and multi-factorial and are likely to be represented by a series of sub-groups with different underlying pain drivers. Both the central and peripheral nervous systems have the potential to mediate PGP disorders. Even in the case of a peripheral pain disorder, the central nervous system can modulate (to promote or diminish) the pain via the forebrain (cognitive factors). It is hypothesised that the motor control system can become dysfunctional in different ways. A change in motor control may simply be a response to a pain disorder (adaptive), or it may in itself promote abnormal tissue strain and therefore be 'mal-adaptive' or provocative of a pain disorder. Where a deficit in motor control is 'mal-adaptive' it is proposed that it could result in reduced force closure (deficit in motor control) or excessive force closure (increased motor activation) resulting in a mechanism for ongoing peripheral pain sensitisation. Three cases are presented which highlight the multi-dimensional nature of PGP. These cases studies outline the practical clinical application of a classification model for PGP and the underlying clinical reasoning processes inherent to the application of this model. The case studies demonstrate the importance of appropriate classification of PGP disorders in determining targeted intervention directed at the underlying pain mechanism of the disorder.

Diagnostische Verfahren zum beruflichen Belastungs- und Bewältigungserleben in der psychosomatischen Rehabilitation

BACKGROUND

Psychosomatic rehabilitation research increasingly agrees that symptom-related therapies need to be supplemented by work-related therapeutic interventions. However, there is a lack of evaluated diagnostic instruments for determination of an indication for and evaluation of specific work-related interventions. This article presents an analysis of the diagnostic quality of work-related self-rating instruments as well as their evaluation from a practical perspective.

METHOD

281 psychosomatic inpatients showing high levels of occupational stress were studied using a set of work-related questionnaires on admission: individual coping skills (AVEM), work-related therapy motivation (FBTM), work satisfaction (ABB), leisure activities, experienced control at work, as well as occupational concerns and social stressors at work. Furthermore a sub-group of 78 patients who had completed a specific work-related group programme during their inpatient treatment were interviewed three months post-treatment. The instruments used were examined for reliability, underlying dimensions (factor analysis), health relevance (correlations with the SCL-90-R total score GSI as health-related external criterion), and sensitivity to change.

RESULTS

(1) Reliability: Measuring procedures fulfilled the requirements of measurement accuracy. (2) Underlying dimensions: Factor-analytical investigations of relevant occupational constructs identified six aspects of occupational coping relevant for rehabilitation practice: "occupational resilience", "occupational (over-)commitment", "occupational gratification", "well-being at work", a motivational factor of "occupational identification vs. withdrawal", and "leisure activities". (3) Health relevance: Variables of "occupational resilience" and "occupational gratification" showed the highest correlations with indicators of psychosomatic health. (4) Sensitivity to change: Work-related instruments proved to be predominantly sensitive to change.

CONCLUSIONS

The work-related self-report instruments proved satisfactorily in application with psychosomatic patients. The findings concerning their diagnostic quality show that they can be recommended in research to evaluate work-related issues. Longitudinal evaluations should include work-related diagnostic instruments to a much larger extent.

Improving volitional competence is crucial for the efficacy of psychosomatic therapy: a controlled clinical trial

BACKGROUND

Although skills of will (volitional competences), such as self-motivation or emotion regulation, are particularly necessary for patients with psychiatric and psychosomatic disorders, it is unknown whether volitional deficits can be reduced and thereby the efficacy of psychotherapy increased. We investigated the effect of a group therapy for improving volitional competence in an inpatient rehabilitation program.

METHODS

In a controlled clinical trial, patients from a rehabilitation clinic participated either in the volition group therapy in addition to the standard cognitive behavioral therapy (volition group, VG) or in the standard cognitive behavioral therapy (standard group, SG). Patients were tested for volitional competence, depressive symptoms, total psychiatric symptomatology, and physical complaints prior to, at the end of inpatient therapy and after 6 months of follow-up (n = 242).

RESULTS

At the end of inpatient therapy, better improvement in volitional competence was observed in the VG than in the SG [e.g. self-motivation: effect size (ES) 0.96 vs. 0.39; ANCOVA: F(1, 209) = 16.58; p < 0.001]. Patients with greater volitional improvements had a better rehabilitation outcome. In the VG, depressive symptoms as well as total psychiatric symptomatology decreased significantly more than in the SG [ES: 1.18 vs. 0.87, F(1, 207) = 4.68, p < 0.05, and ES 1.12 vs. 0.73, F(1, 205) = 4.68, p < 0.05, respectively], but not physical complaints [ES: 0.62 vs. 0.48, F(1, 207) = 1.08, n.s.].

CONCLUSIONS

Effect size increased in patients with initially low volitional competence and high motivation to participate in a volitional training. These results might lead to a more systematic assessment and training of volitional competence.

[A new scale for measuring return-to-work motivation of mentally ill employees]

A new scale "motivation for return to work" has been constructed to measure depressive patients' motivation to start working again in a stepwise process. The scale showed in 46 patients of a first case management (CM) sample with depressive employees a good correlation with the final social status of the CM. Only the motivated patients were successful returning to work and could be, separated clearly from the most demotivated one. Second, the scale correlated with the duration of sick leave and third showed an inverse correlation with the complete time of CM, suggesting that a successful stepwise return to work requires time. These first results need further examination.

[Effects of therapy goal oriented cognitive behavioural aftercare measures on therapy transfer following inpatient psychosomatic rehabilitation]

OBJECTIVE

After discharge from inpatient psychosomatic rehabilitation patients often face problems to transfer and stabilize the modifications they have achieved in the clinic. Using targeted outpatient aftercare interventions up to eight weeks after discharge from the inpatient programme we tried to support this transfer, thus enhancing treatment effectiveness.

METHOD

The evaluation was carried out as a field experiment. Patients were matched into pairs and then allocated randomly to either a control or an experimental condition. The experimental group, which had participated in specific aftercare measures after inpatient therapy, was compared to the control group at "discharge from clinic" and "twelve weeks post-discharge" relative to a number of variables relevant in therapy outcome.

RESULTS

Twelve weeks post-discharge patients who had participated in aftercare measures show significantly better progress relative to their physical and psychological complaints than patients in the control group. Also, they are more capable of coping with psychosocial demands of their everyday life. They experience better control of their symptoms and they are more successful in attaining the goals they have set for themselves for the time after discharge.

CONCLUSIONS

The findings show that supplementing psychosomatic inpatient rehabilitation with specific aftercare measures will lead to better transfer and to increased effectiveness of psychosomatic rehabilitation. Also on account of our results, outpatient rehab aftercare programmes have in the meantime become a regular component of inpatient psychosomatic rehabilitation in Germany.

The association of parental monitoring and family structure with diverse maladjustment outcomes in middle adolescent boys and girls

The aim of this study was to study the associations between family structure, parental monitoring and maladjustment outcomes among middle adolescent girls and boys. Data was collected through a school-based survey of a nationally representative sample of 17,643 Finnish adolescents aged 14-16 years. The less the parents knew the adolescents' friends and whereabouts, the more common were all the maladjustment outcomes studied. Non-intact family structure was associated with maladjustment and had associations independent of parental monitoring. We conclude that parental involvement with adolescents is conducive to healthy development, and that adolescents need the protection provided by parental supervision. Knowing the adolescent's whereabouts and friends is a concrete and easily measurable way of assessing parents' involvement in the adolescent's life.

Die Vor- und Nachbehandlung in der stationären psychosomatischen Rehabilitation

Patients who are referred to psychosomatic inpatient rehabilitation are mostly suffering from long-term illnesses. Therefore, it is necessary to take pre- and post-treatment into account. Epidemiological questions are frequency and type of pre- and post-treatment and their relation to course and outcome of rehabilitation. Pre-treatment, recommendations for follow-up treatment, and course of treatment in 1284 patients of the department of behaviour therapy and psychosomatics of the rehabilitation centre Seehof were assessed. Before admission, 75.4 % of patients had been in psychiatric treatment, and 31.3 % had received psychotherapy. The inpatient stay was significantly longer in patients with psychiatric pre-treatment and those with a combination of psychiatric treatment and psychotherapy. These patients were more often unemployed and showing an insufficient social network. Pre-treatment was unrelated to changes in the SCL-90-R, to physician ratings of therapeutic outcome or the ability to work at the end of rehabilitation. Patients pre-treated by a general practitioner, psychiatrist or psychotherapist returned to that therapeutic setting after rehabilitation. Patients only treated by general practitioners were referred to specialist treatment. These data show the need to integrate inpatient rehabilitation in long-term pre- and post-treatment. One effect of inpatient rehabilitation is to optimize treatment. This requires good communication across different areas of health care.

Nachhaltigkeit orthopädischer Rehabilitation bei chronischen Rückenschmerzen - Das Integrierte orthopädisch-psychosomatische Behandlungskonzept (IopKo)

Chronic diseases of the musculoskeletal system rank first as causes of early retirement in Germany. Therefore orthopaedic rehabilitation has to identify patients with work-related problems and to promote return to work through differential treatment and vocational counselling. In the framework of the IopKo-Project such measures were developed and evaluated. These measures encompass: (1) an intensive and multiprofessional diagnostic pathway which allows early detection and treatment of mental disorders and job related problems; (2) homogeneous treatment groups based on multiprofessional diagnostics; (3) differential treatments, among these a multidisciplinary programme for patients with chronic low back pain or high risk of chronification (Rückenfit); (4) interactive training modules which mediate principles of performance and disability expertise, the legal bases of retirement pensioning, and measures to support occupational rehabilitation; and (5) a work hardening training programme.

METHOD

To evaluate the effects of these measures in comparison to a control group with usual care, a prospective longitudinal study was conducted. A total of 307 patients were assigned to the multidisciplinary in-patient treatment programme, whereas 176 patients in the control group had a standard rehabilitation programme.

RESULTS

The results show positive moderate and strong effects in the intervention group concerning function, pain, psychic strains as well as the number of sick days and return to work rates 10 months after discharge. The effects in the intervention group exceeded the effects achieved in the control group. PATIENTS WITH HIGH RISK OF CHRONIFICATION: Beside the full sample, a subgroup of patients with chronic pain or high risk of chronification was analyzed, who had received a multidisciplinary functional restoration treatment. Also for this subgroup we found moderate and strong effects of treatment for function, psychic strains and sick days superior to those in the control group.

CONCLUSION

By this study we were able to show that orthopedic rehabilitation in a multimodal and multidisciplinary setting with a focus on activating and motivating therapy can have sustainable positive effects on pain, function and psychic well-being as well as on economic parameters. We interpret these persistent and superior effects in the treatment group (1) as a result of multiprofessional diagnosis and assignment which helps to subdivide the inhomogeneous group of patients with unspecific back pain into more homogeneous and thus more effective subgroups, (2) as a result of increased motivation by closed treatment groups, (3) as a result of intense and multilevel counselling of work related problems, (4) as a result of work hardening modules, and (5) as a result of direct and efficient treatment of psychic strains. The results also demonstrate the significance of inpatient rehabilitation, which will be efficient if differential treatment - adequate to the problems of the patient - is offered.

[Acceptance of a psychometric routine diagnostics and quality monitoring system among psychotherapists in inpatient psychosomatic rehabilitation]

OBJECTIVE

Psychotherapists are considered to be sceptical of empirical measures of quality assurance. It is generally recognised that the success of these measures mainly depends on how they are accepted by the people involved.

METHODS

The acceptance of a quality monitoring system among psychotherapists was investigated with a standardised assessment instrument.

RESULTS

Practical relevance and practicability of the system were judged positively on the following dimensions: "support of clinical diagnostics", "examination of the outcome", "reflecting on the therapeutic process", "documentation", "integration in the therapeutic process", "pressure to succeed and control" and "work loading". The factors "professional experience", "profession" and "sex" had just a small influence on the degree of acceptance of the quality monitoring system.

CONCLUSIONS

Psychotherapists consider a practically relevant and economical quality monitoring system as useful.

[Treatment results from inpatient psychosomatic rehabilitation of Turkish migrants: a prospective study]

Psychosomatic rehabilitation and the concluding social-medical assessment constitute a particular challenge. The aim of this study was to examine whether inpatient psychosomatic rehabilitation in the context of an integrated treatment concept, conducted in Turkish and German, is effective in the rehabilitation of Turkish migrant laborers, and what concluding socio-medical assessment results from this treatment. 195 Turkish patients--44 male and 151 female--received inpatient psychosomatic treatment for approximately 40 days. Sociodemographic, psychiatric and social-medical data were recorded, as well as Symptom Checklist (SCL-90-R) testing upon admission and discharge. A predominant number of patients were laborers, with a low level of primary education, who were afflicted with psychosocial problems and dissatisfaction with their workplace and who first came into psychosomatic treatment many years following the onset of their illness. Many of them had a clearly defined desire to retire. At the end of their admission, a significant improvement in almost all the scales of the SCL-R-90 was ascertained on the one hand, but on the other, adequate socio-medical results were hardly observed. The symptoms' improvement would confirm that the combination of service offerings in Turkish and German proved themselves. A portion of the patients (approx. 40 %) were classified subsequent to treatment as capable of working for 6 hours or more. Nevertheless, approximately approx. 75 % still sought to retire. Timely psychosomatic treatment could counteract chronification of the illness and the establishment of a steadfast desire to enter retirement, and consequently represent an improvement in the prognosis. Likewise, consistent psychosomatic training of physicians, as well as systematic prophylactic measures with the migrant laborers, should be considered.

Improvement of balance between work stress and recovery after a body awareness program for chronic aspecific psychosomatic symptoms

OBJECTIVE

A 3-day residential body awareness program (BAP) was developed to teach people with chronic aspecific psychosomatic symptoms (CAPS) to react adequately to disturbances of the balance between a daily workload and the capacity to deal with it. The long-term effects of the program in improving the balance between work stress and recovery are presented in this study. The intervening effect of 'improved balance' on quality of life is also analysed.

METHODS

A pre-post design is used with post-measures at 2 and 12 months after the program, without controls (n = 122). Mean age is 42.5 years (S.D. = 9.0) and 60% of participants are female.

RESULTS

The results show participants become more active physically and socially, and at the same time take the opportunity to recover. There was a difference measured in changing balance for participants who are fully employed and participants who are not working or are working part-time due to health problems: the second group reintegrated into work, the first group spent more time socialising inside the family. Personal goals are realised by 85% of the participants. Realising personal goals and becoming more active is a mediating factor for increasing quality of life. The majority of the measured changes can be interpreted as clinically relevant outcomes with medium-to-large effect sizes. Spouses of the participants also confirm these effects.

DISCUSSION AND CONCLUSION

Evaluation of the BAP gives evidence to conclude that this program leads to long-term effects in CAPS. Participants react more adequately to disturbances between daily workload and the capacity to deal with this load. Two and 12 months after the 3-day program, they changed their behaviour to a more active lifestyle and increased self-management in coping with stress and psychosomatic symptoms.

PRACTICE IMPLICATIONS

By paying more attention to the balance between work stress and recovery, patient educators may be able to increase their effectiveness. Personal goal realization can be effective in guiding people by getting them out of the negative spiral.

Vocational training integrated into inpatient psychosomatic rehabilitation--short and long-term results from a controlled study

PURPOSE

The aim of this study was to determine the impact of a vocational training programme on short- and long-term results after psychosomatic rehabilitation.

METHOD

1,590 inpatients were screened for vocational integration. A high-risk group of 266 patients was randomly assigned to the vocational training programme plus psychosomatic treatment; treatment- as- usual served as a control condition. An occupational training was conducted at local companies, closely integrated into psychosomatic treatment. Vocational attitudes and adjustment were studied at intake, discharge, three, 12 and 24 month follow-ups.

RESULTS

More than half of the study participants were unemployment and/or long-term work-disabled harbouring strong negative attitudes toward return to work. Forty-six percent of the intervention group declined from participation, but complied with follow-up investigation. At discharge, participants of the vocational training programme had become more optimistic regarding resuming work. One year following discharge, participants of the training programme reported less absence from work. After 24 months, vocational adjustment had improved considerably among programme participants, and declined among controls and refusers.

CONCLUSION

An intensive vocational training programme is effective in promoting positive attitudes to work, reducing work disability and promoting return-to-work. However, a randomized design may be not optimal; evaluation necessitates long-term follow-up.

The long-term lasting effectiveness on self-efficacy, attribution style, expression of emotions and quality of life of a body awareness program for chronic a-specific psychosomatic symptoms

OBJECTIVE

A 3-day residential body awareness program (BAP) was developed to teach people with chronic a-specific psychosomatic symptoms (CAPS) to react adequately to disturbances of the balance between a daily workload and the capacity to deal with it. The long-term effects of the program on body awareness, psychological factors, psychosomatic symptoms and quality of life for people with CAPS are presented in this study.

METHODS

A pre-post design is used with post-measures 2 and 12 months after the program, without controls (n = 122). Mean age is 42.5 (S.D. = 9.0) and 60% is female.

RESULTS

The results showed an increase of body awareness, self-efficacy, expression of emotions and quality of life. Stress-related symptoms decreased and the attribution style was found to be less depressive. Participants achieved significantly higher levels of functioning at 2 months which increased significantly more at 12 months. The majority of the measured changes can be interpreted as clinically relevant outcomes with medium-to-large effect sizes. Spouses of the participants also confirm the found effects.

DISCUSSION AND CONCLUSION

Evaluation of the BAP gives evidence to conclude that this program leads to the theoretically expected long-term effects in CAPS. Participants react more adequately to disturbances between daily workload and the capacity to deal with this load. Two and 12 months after the 3-day program, they are more capable of self-management in coping with stress and psychosomatic symptoms.

PRACTICE IMPLICATIONS

This article sheds new light on the difficulties that individuals with psychosomatic symptoms and their professional interventionists encounter when attempting to manage the chronicity of the problems. By paying more attention to learning self-management by increasing body awareness and self-efficacy, patient educators may be able to increase their effectiveness.

[How relevant are the benefits for participation at working life for psychosomatic inpatient rehabilitation]

Beside the stabilization of the health status the reintegration into employment are the main ambitions of the medical rehabilitation. Thereby occupational rehabilitation plays an important role in the rehabilitation system. To recommend occupational rehabilitation physicians have to know the requirements patients have to comply with. In addition formal conditions of the medical report upon discharge have to be accomplish that benefits for participation at working life will be provided by the pension insurance. In our study the differences of the amount of recommendation for occupational rehabilitation and the appraisal of the ability to work in the medical reports upon discharge of psychosomatic and orthopaedic patients are examined. The results show that psychosomatic patients achieved significantly less recommendations for occupational rehabilitation than orthopaedic patients. At the same time more psychosomatic patients who achieved the recommendation didn't claim benefits for participation at working life. In addition orthopaedic patients get a rehabilitation approval certification more often than psychosomatic patients. At the same time it appears that maybe the recommending clinics were insecure about the connection between the occupational capacity assessment and the recommendations for benefits for participation at work life. The outcomes presume that work place problems in medical rehabilitation are not taken into consideration adequately.

Centralization: association between repeated end-range pain responses and behavioral signs in patients with acute non-specific low back pain

OBJECTIVE

Tests and measures, if confounded by behavioral signs, cloud interpretation of physical test results during clinical examination. The purpose of this study was to determine whether common behavioral signs and pain responses (i.e. centralization and non-centralization) were associated during initial examination.

DESIGN

Observational and designed to cross-tabulate pain responses to behavioral signs.

PATIENTS

Data from 177 consecutive patients with acute work-related low back syndromes referred to physical therapy were analysed.

METHODS

Patients were screened for 8 baseline behavioral signs. Pain responses during initial evaluation were determined from repeated end-range trunk movement tests or loading strategies following McKenzie assessment methods. Association between centralization and non-centralization and baseline behavioral signs were assessed.

RESULTS

The physical sign of non-centralization was associated with non-organic signs, overt pain behaviors, fear of work activities, and somatization. Although depression, fear of physical activities, disability and pain intensity were not associated with non-centralization (p>0.05), upper bounds of odds ratios confidence intervals suggest that these behavioral signs may not be entirely independent of pain responses.

CONCLUSION

Presence of non-centralization is associated with many behavioral signs, and therefore when present, clinicians should consider additional psychosocial screening during the initial evaluation.

[Neurofeedback-based EEG alpha and EEG beta training. Effectiveness in patients with chronically decompensated tinnitus]

BACKGROUND

Persisting tinnitus is an often devastating disease condition with restricted and rarely successful therapeutic options.

PATIENTS AND METHODS

The present study investigates the therapeutic effect of short term neurofeedback-based EEG-Alpha- and EEG-Beta-training in 40 patients suffering from "chronic decompensated tinnitus". Patients were assigned to the Alpha or Beta group according to results of an initial EEG monitored stress-test. Four patients were excluded because they showed abnormal reactions in both EEG patterns.

RESULTS

During 12 sessions, 23 patients succeeded to increase EEG Alpha activity by 16% (p< or =0.042) while 13 patients achieved no decrease of EEG Beta activity. However, both groups showed a significant reduction of subjective tinnitus annoyance by the end of the therapy (p< or =0.001)

CONCLUSIONS

The results indicate that neurofeedback may represent a new promising technique in the therapy of chronic decompensated tinnitus. However, it remains to be established whether the reduction of tinnitus annoyance results from the altered brain activity patterns supported by the neurofeedback learning process.

[An empirical structural analysis of the IRES questionnaire version 2, dependent on indication, gender and age]

The patient questionnaire "Indicators of Reha Status" (IRES, Version 2) is used for assessing the need for rehabilitation and the success of rehabilitation. It is one of the most frequently used questionnaires in measuring subjective health conditions in medical rehabilitation in Germany. Based on the data of 8600 inpatient rehabilitees, the underlying structural model is examined by a confirmatory factor analysis. The model deviates in part from the original model of the questionnaire authors. The modified model was tested within 12 sub-groups. The sub-groups were divided depending on sex, age and indications (orthopaedic, cardiologic and psychosomatic) of the patients. Multi-group comparisons made between those 12 sub-groups showed specific structures within the groups of psychosomatic patients while no differences between female/male and younger/older patients were found. Furthermore, comparable structures of orthopaedic and cardiologic patients were found. Therefore the dimension values of the IRES patient questionnaire are not suited for a comparison between psychosomatic patients and patients from the somatic indications.

Tinnitus aus Sicht des in der Praxis t�tigen HNO-Arztes

Tinnitus lasting for more than 3 months is considered chronic. It is not a self-contained illness as such, but a symptom of a central information processing malfunction with individually distinguishing emotional reactions. However, it can, as chronically decompensated tinnitus, manifest itself as an ailment which is more or less pronounced in the person afflicted, and it can also, as a subjective sensation, be the symptom of an objective illness which must be excluded by differential diagnosis. In the majority of cases of chronic tinnitus, psychological components play a substantial role and must be taken into account in diagnosis. As a rule, no therapeutic impact can be made on chronic tinnitus. The doctor's target is therefore to achieve and stabilise habituation in the person afflicted so that, although the tinnitus will continue to exist, it will no longer be perceived as burdensome. Amongst the causes or contributory factors of tinnitus are dysfunctions of the upper cervical vertebral column and/or of the mandibular joints. In cases of tinnitus, these should always be diagnostically clarified and, wherever possible, eliminated to make habituation easier and to diminish the likelihood of recidivism.

Motivation zur psychosomatisch-psychotherapeutischen Bearbeitung von beruflichen Belastungen - Entwicklung und Validierung eines Fragebogens

BACKGROUND

There is a lack of questionnaires assessing the motivation of inpatients to scrutinize occupational stresses and deal with them as part of their psychotherapeutic treatment. Work-related stress contributes significantly to the development of mental disorders. Vocational reintegration is an outcome criterion for the success of vocational rehabilitation. Patients are often not motivated for dealing with occupational stresses during inpatient medical rehabilitation. Therefore it is necessary to assess patient motivation at the beginning of treatment, in order to assign them to specific interventions, e. g. promoting motivation.

METHOD

A questionnaire (Fragebogen zur berufsbezogenen Therapiemotivation -- FBTM) consisting of 84 items was developed, based on published questionnaires for psychotherapy motivation. 283 psychosomatic rehabilitation inpatients were administered the FBTM, subsequently analyzed by item and factor analyses. Based on a second sample (n = 282) confirmatory factor analyses and validation of the questionnaire were executed.

RESULTS

Item and factor analyses revealed a four factor structure. 24 items constituted the subscales that could be described as "intention to change", "wish for pension", "negative treatment expectations" and "active coping". Reliability (Cronbach's Alpha) was satisfactory with coefficients between 0.69 and 0.87, and only low correlations could be found between the four subscales. Correlations with other measures were most pronounced for the subscale "intention to change". Some significant but low correlations could be reported between the FBTM and a standardized questionnaire of psychotherapy motivation (FMP). Confirmatory factor analyses of a second sample (n = 282) confirmed the original four factors. First evidence of sensitivity could be observed in a sample of patients who took part in an intervention promoting work-related therapy motivation during psychosomatic inpatient rehabilitation.

CONCLUSIONS

The FBTM is a reliable and valid instrument assessing work-related therapy motivation of inpatients, as a relevant therapeutic measure in psychosomatic rehabilitation. Further validation, especially the analysis of predictive validity is desirable.

Ergebnisqualität psychosomatischer Rehabilitation: Zielerreichungsskalierung auf der Basis einer strukturierten Therapiezielliste

Within the scope of a multicenter study regarding the outcome quality of inpatient psychosomatic rehabilitation a structured catalogue of therapy goals (SZK, strukturierter Therapiezielkatalog) was developed. The catalogue contains 89 predetermined therapy goals as well as the option to formulate further goals in own words. The SZK is available both as a patient and as a therapist version. At the beginning of treatment up to five primary objectives are chosen from the list. At the end of treatment and at the 1-year follow-up the level of achievement of objectives is assessed. Moreover the SZK contains the option to mark goals as not relevant any more and to add goals which came up during the treatment and to evaluate them regarding the level of achievement. The study on hand asks for empirical identification of the target structure. Furthermore, reliability and validity of the calculated measures of goal attainment are analysed. As the most important finding the SZK turns out to be a practical and economical assessment instrument for goal-oriented evaluation.

[Cluster formation - an operationalization of rehabilitation success in rehabilitants with chronic low back pain]

To investigate the impact of the way of allocation for rehabilitation on rehabilitation success in patients with chronic low back pain it was necessary to define appropriate criteria of success. A multidimensional model of success is presented in this article. First, the outcomes of rehabilitation are described and statistically tested. No statistically or clinically relevant changes between pre and post measurements were found. For further analysis of predictors and group comparisons it is necessary to define multidimensional success. For this purpose, cluster analyses are introduced as a possible model, resulting in three groups of patients with differing outcomes, i. e.: 20 % patients with declined pain symptoms, 40 % patients without any changes, 40 % patients with increased symptoms. No impact of the way of allocation for rehabilitation could be verified.

[Work-related stress and resources of psychosomatic patients compared to the general population]

Work-related stress is an important determinant of the development of psychosomatic complaints and of the success of psychosomatic treatments. In order to specify work-related stress and resources in relation to the general population, 461 consecutive inpatients in psychosomatic rehabilitation were compared to matched pairs (age, sex, occupational status) from a representative community survey, the German Socio-economic Panel (GSOEP). Psychosomatic inpatients reported overall higher work stress than their matched pairs of the general population, the rank order of the stress factors as well as sociodemographic and occupational determinants were comparable. Patients also rated resources lower than their matched pairs. They reported much higher strains due to conflicts with supervisors and found less support among their colleagues. The items studied are useful to describe work stress profiles of psychosomatic rehabilitation patients and serve as a basis for therapeutic work.

[The increase in psychological and psychosomatic disorders: consequences for workman's disability claims management and rehabilitation practice]

The increase in psychological, psychosomatic and chronic diseases is a challenge to claims managers and health experts in the field of rehabilitation. This change highlights the limitations of a diseases-orientated disability concept and forces insurers to rethink claims management procedures.

Verminderung von Technologie�ngsten in der psychosomatischen Rehabilitation?Konzepte und Ergebnisse zu einem Computertraining f�r �ltere Arbeitnehmer*

A computer training program was developed specifically oriented toward middle-aged employees, their learning needs and their computer-related fears. This program was based on a pilot study showing a high degree of stresses associated with the introduction of computer technology at the workplace in this age group (50-59 years). A survey of 623 patients confirmed that these persons experienced technological change predominantly as disadvantageous or threatening. Based on 114 patients, concepts and results of the computer training are presented. Participation reduced avoidance behaviors, fears and increased interest and initiative based both on the patients' and their trainers' perspectives.