[AMIKA: psychometric evaluation of a photo-based scale for the assessment of fear avoidance beliefs in elderly individuals]. / AMIKA: Altere Menschen in körperlicher Aktion.

BACKGROUND: Confrontation therapy proved to be effective in the treatment of fear avoidance beliefs (FAB). Prior to treatment, it is necessary to establish a hierarchy of activities according to their perceived health hazards. For this purpose, we developed the AMIKA scale, which consists of 50 photos showing elderly individuals engaged in daily activities, and investigated its psychometric properties. METHODS: We conducted a cross-sectional study with repeated measurement after 4 weeks. At the time of both measurements, apart from AMIKA, we assessed pain, disability, FAB, and physical activity. Furthermore, we used ultrasound topometry for the assessment of flexion and extension of the lumbar spine. At t1, a total of 103 elderly individuals with chronic low back pain participated in the study. Their average age was 71.41 years (SD = 5.2). Of these, 67 attended the t2 assessment. RESULTS: Retest reliability amounted to r=0.63 and internal consistency was alpha=0.97. Correlations of the AMIKA scores with pain and disability demonstrated large effect sizes, whereas effect sizes regarding other related FAB scales remained in the medium range. No correlations at all were found with respect to the objective ultrasound measurements and to self-reported physical activity. CONCLUSIONS: The results allow the use of AMIKA as an instrument for the generation of a FAB hierarchy in the context of confrontation treatment.

[Assessment of pain in advanced dementia. Construct validity of the German PAINAD]. / Beurteilung von Schmerz bei Demenz (BESD). Untersuchung zur Validität eines Verfahrens zur Beobachtung des Schmerzverhaltens.

BACKGROUND: The observation scale PAINAD (pain assessment in advanced dementia) is composed of five behavioral categories: breathing, vocalization, facial expression, body language, and consolability. The present study investigates the construct validity of the German version. PATIENTS AND METHODS: We conducted a prospective one-dimensional observation study with repeated measurements (t(1)=pretreatment, t(2)=2 h posttreatment, t(3)=24 h posttreatment). The sample consisted of 12 verbally noncommunicative demented inpatients with severe comorbidity treated in three geriatric clinics. Their age was M=84.3 years (SD=4.4) on the average. Ten of them were female. Inclusion criteria were pain-related physical illness and observed pain behavior. Every patient was treated with analgesics after t(1). After t(2) the medication was discontinued in five patients until t(3). Nurses documented the PAINAD scores after an observation period of 2 min during routine care. RESULTS: Pain behavior at t(2) diminished considerably displaying a large effect size. Scores continued to be low at t(3) only in the sample with continued medication. Scores in the other part of the sample returned to initial values. CONCLUSION: The data demonstrate that pain medication strongly impacts the pain behavior of demented patients. The outcome supports the assumption that PAINAD really measures pain.

[Fear Avoidance Beliefs and physical function in elderly individuals with chronic low back pain]. / Fear Avoidance Beliefs und Funktion bei älteren Personen mit chronischem Rückenschmerz.

Fear Avoidance Beliefs and physical function in elderly individuals with chronic low back pain This analysis assessed how fear avoidance beliefs (FABs) affected subjective and objective functional parameters as well as pain in elderly individuals. The study comprised 152 elderly patients with low back pain, which was attributed to spondylosis in almost half of the cases. Their average age was 70.1 years (SD=4.3, range 65-84). All of the patients participated in a physiotherapeutic program including data acquisition before treatment (t1), immediately after its completion (t2), and 6 months later (t3). FABs were assessed by a five-item scale with satisfying psychometric properties. The primary outcome criterion was function, which was evaluated as a subjective measure using the Hannover functional disability scale and as an objective measure based on the anteflexion determined by ultrasound topometry. Secondary outcome criteria were pain parameters. At the time o the first measurement (t1), the patients were classified into three groups with strong, intermediate, or weak FABs. Analyses of variance reveal an improvement of subjective functional capacity in every FAB group between t1 and t2. At t3, there is a decline of these values only in the group of the high fear avoiders. High fear avoiders also show lower values in the objective measure at all three measurement points. No influence of the FABs on the pain parameters could be determined. It would be expected that the efficacy of physiotherapy could be improved if the patients' FABs are taken into consideration when planning the treatment regimen.

[Diagnosis and treatment of pain in the elderly patient]. / Zu selten berichtet, zu selten diagnostiziert, zu selten therapiert. Nehmen Sie Schmerz nicht als normale Alterserscheinung hin!

For the diagnosis of pain in the elderly patient, special instruments are available for measuring cognitive and sensory deficits. With regard to treatment, too, age-specific peculiarities must be taken into account. Musculoskeletal diseases, and especially osteoarthritic conditions, are the most common pathologies that are the cause of pain in old age. To a particular degree they result in a restriction of mobility and pose a threat to the patient's independence. Physical inactivity is a major risk factor for the development of chronicity and for patient withdrawal. An improvement in the patient's training status can be achieved by pharmacological and physical treatment applied in association with active physical exercise and psychological measures.

[Pain assessment and pain treatment in the geriatric patient. Part II: pain treatment]. / Schmerzdiagnostik und -therapie in der Geriatrie. Teil II: Schmerztherapie.

A primary goal of pain treatment in geriatric patients consists of maintaining physical and mental function, which is a precondition of activity and participation. In patients with chronic pain, multidisciplinary treatment without excluding invasive procedures is the most effective approach. The medication ladder, suggested by the WHO initially for cancer pain, provides a guideline for pharmacological treatment. Due to age-dependent alterations in the kinetics and dynamics of pharmaceuticals, the titration of the medication follows the rule "start low and go slow." The same principle holds true for the maintenance or augmentation of physical activity in order to escape from the activity-deconditioning cycle. The training should be based on learning theories, include pain management strategies, and incorporate psychological approaches to facilitate the active participation of the patient in the treatment program. In hospitals and nursing homes, nurses play an important role in defining the need for pain treatment and in supervising the patient in the treatment process. Despite all these endeavors, a significant number of patients remains whose pain cannot be controlled sufficiently. Euthanasia on demand of the patient with untreatable pain is not admitted in Germany.

[Influence of pain perception, morbidity and mood on functional impairment in elderly chronic pain patients]. / Einfluss von Schmerzwahrnehmung, Morbidität und aktueller Stimmung auf funktionelle Beeinträchtigung Alterer mit chronischen Schmerzen.

The purpose of the study was to address the impact of pain perception, morbidity and mood on functional impairment in elderly chronic pain patients. Multimorbid pain patients beyond the age of 65 in two geriatric hospitals (n = 84), a pain clinic (n = 60) and three general practices (n = 117) provided information about pain perception, comorbidity, additional symptoms and mood by means of the "Structured Pain Interview for Geriatric Patients", the "Cumulative Illness Rating Scale" and a list of symptoms. Data analysis relied on stepwise multiple regression with variables of pain perception entered in the first step, of morbidity entered in the second step and of mood entered in the third step. Although patients believe that pain is the main reason for their functional impairment (71.3%), the data do not support this assumption. Increasing morbidity and bad mood have more impact to reduced functional performance than the pain perception. Our results support the recommendation that a multimodal program should be offered to even multimorbid and older people with chronic pain in order to achieve a maximum of functional rehabilitation.

[Pain assessment in the geriatric patient. Part I: pain diagnostics]. / Schmerzdiagnostik und -therapie in der Geriatrie. Teil I: Schmerzdiagnostik.

The geriatric pain patient is a frail patient at risk of losing the ability to take care of him/herself and, therefore, at risk of losing personal independence. There is a growing probability of comorbidity and of cognitive impairment with increasing age. One of the main objectives of geriatrics is the preservation and promotion of the capacity to perform everyday tasks (activity) and to participate in social life (participation). Comorbidity impacts on disability to a higher degree than pain does. Cognitive restrictions contribute to a decreased validity of the assessment instruments. For these reasons, geriatric assessment has to be multidimensional and has to take into account the patient's psychological and social situation in addition to the pain and physical status. In geriatrics, a set of standardized instruments is used to accomplish this task. It may not be practical to handle the whole set in the practice of the pain specialist; nevertheless, some simple measures for the assessment of functional as well as cognitive status should be incorporated into the diagnostic procedure for the elderly pain patient. Written questionnaires should not be used in cases of sensory or cognitive impairment of the patient. The adequate tool for these patients is a structured pain interview.

[Pain treatment in geriatric patients]. / Schmerztherapie in der Geriatrie.

A primary goal of pain treatment in geriatric patients is the maintenance of physical and mental functions. This is a precondition for activity and participation. In patients with chronic pain, multidisciplinary treatment, without excluding invasive procedures, is the most effective approach. The medication ladder, initially suggested by the WHO for cancer pain, provides a guideline for pharmacological treatment. Due to age-dependent alterations in the kinetics and dynamics of pharmaceuticals, the titration of the medication follows the rule "start low-go slow". The same principle holds true for the maintenance or augmentation of physical activity in order to escape from the activity-deconditioning cycle. Training should be based on learning theories, include pain management strategies, and incorporate psychological approaches to facilitate the active participation of the patient in the treatment program. In hospitals and nursing homes, nurses play an important role in defining the need for pain treatment and in supervising the patient in the treatment process. Despite these endeavours, a significant number of patients remain whose pain cannot be controlled sufficiently. Euthanasia on demand for a patient with untreatable pain is not admitted in Germany.

[Comorbidity, multiple medication, and well-being in elderly patients with chronic pain]. / Komorbidität, Multimedikation und Befinden bei älteren Patienten mit chronischen Schmerzen.

Consecutive patients with a minimum age of 65 years and at least one additional diagnosis participated in a standardized interview during the initial assessments in two geriatric hospitals ( n=86), a multidisciplinary pain center ( n=60), and three primary care practices ( n=117). The average age of the total sample was 76.29 years (SD=7.40); females constituted 73.3% of the sample. The average number of drugs consumed by the patients amounted to 7.31 (SD=2.66) with a maximum number of 19 drugs. Nearly three-quarters of the patients indicated a reduction in their pain by avoiding physical activity. Every second patient often felt depressed and without energy. The most frequent symptoms were a dry mouth, sleep disorders, fatigue, constipation, and dizziness. Patients from the geriatric hospitals were older and better educated, reported fewer painful body regions, indicated lower intensity and duration of pain as well as a lower number of pain medications. On the other hand, they were characterized by a higher intensity of comorbidity and by increased functional impairment. Patients from the pain clinic suffered more frequently from pain in the hip and the pelvis. They took stage I analgesics more often and admitted more frequently to adjusting the drug consumption to changes in well-being and situational factors. They felt the highest amount of impairment in their social activities. Nevertheless, they expressed the highest confidence in future improvement.

[Deficits in the psychological care of low back pain patients--Comments on the expertise of the expert committee for the health care system regarding low back pain]. / Zur psychologischen Unterversorgung von Kreuzschmerzpatienten--Stellungnahme zu dem Gutachten des Sachverständigenrates für das Gesundheitswesen zum Thema Rückenleiden

A committee of health specialists examined the demand characteristics and efficiency of German health care services and published an expertise on the misallocation of services that among other subjects also covered the area of low back pain. Although we agree with their principal statements, we like to underscore that the objectives mentioned in the report cannot be achieved without the participation of psychologists. The process of chronicity is determined in a significant way by psychological mechanisms. Psychologists investigated these mechanisms, developed interventions for the prevention and treatment of low back pain on the basis of the results, and tested their efficacy in trials with a high methodological standard. Incorporation of psychological expertise does not only optimise prevention and treatment of low back pain and helps to prevent unnecessary suffering of the afflicted, in addition, it offers a contribution a cost containment.

[Results of early mobilisation of acute whiplash injuries]. / Ergebnisse der frühfunktionellen krankengymnastischen Ubungsbehandlung nach HWS-Distorsion.

BACKGROUND: Diagnostic evaluation and therapeutic management of acute neck pain after whiplash is a frequent but unsolved clinical problem. Long-lasting symptoms and disability are common. Former studies proposed beneficial effects of physiotherapy in the early management of whiplash injury. The purpose of this study was to assess the effects of early active mobilization versus standard treatment with a soft cervical collar. METHODS: Between August 1997 and February 2000 a prospective randomized clinical trial with a total of 168 patients was performed. Of these patients 81 (31 male, 50 female; average age 28,78 years) were randomly assigned to the standard therapy group, which received a soft cervical collar, and 87 (31 male, 56 female; average age 29,62 years) to the early mobilization group, treated by physiotherapy. Study participants documented pain and disability twice (baseline and six week follow-up) during a one week period by diary, using numeric rating scales ranging from 0 to 10. RESULTS: The initial mean pain intensity (4,75) reported by the standard therapy group was similar to disability (4,76). There were no significant differences to initial pain (4,50) and disability (4,39) reported by the early mobilization group. The mean pain intensity reported by the standard therapy group after 6 weeks was 2,66 and disability was 2,40. The mean pain intensity indicated by physiotherapy group was 1,44 and mean disability was 1,29. The differences between the groups were both significant. CONCLUSIONS: Early mobilization is superior to the standard therapy regarding pain intensity and disability. We conclude that mobilization should be recommended as the new adequate standard-therapy in the acute management of whiplash injury.

Readiness to adopt adequate postural habits: an application of the Transtheoretical Model in the context of back pain prevention.

Based on a biomechanical model, an adequate body posture can contribute to the prevention of back pain and back pain chronicity. This study examines the explanatory value of the Transtheoretical Model (TTM) for the adoption of adequate postural habits in a cross-sectional sample of 149 employees of a German administration unit (mean age 40.2 years, 50% female). Using newly developed instruments with satisfactory psychometric properties, basic assumptions of the TTM could be confirmed: self-efficacy and the perceived pros for maintaining a good body posture increased significantly across the stages, while the perceived cons decreased. Additionally, the use of preventive strategies for back pain prevention increased linearly and significantly across the stages of change. The study supports the applicability of the TTM for postural behavior. Considering stages of change as an intervening variable may contribute to clarifying the relationship between participation in low back schools and prevention of back pain chronicity. Longitudinal and intervention study data are needed to support these assumptions.

[A structured pain interview for geriatric patients]. / Ein strukturiertes Schmerzinterview für geriatrische Patienten.

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.

Improving physician-delivered counseling in a primary care setting: lessons from a failed attempt.

BACKGROUND: The high prevalence of behavioral risk factors for cardiovascular diseases demands innovative approaches to achieving behavior change. Primary care physicians are in an ideal position for offering such interventions. PURPOSE: To evaluate whether training of primary care physicians in counseling skills based on the Transtheoretical Model (TTM) leads to motivational and behavioral changes in their patients. METHOD: Seventy-four primary care physicians in Germany were randomly assigned to either an intervention condition (one day of training in TTM-based counseling plus brochures matched to their patients' "stages of change") or a control condition (usual care). Baseline and 12-month follow-up data were collected from 305 of their patients who signed up for a health check-up. OUTCOME MEASURE: Patients' movements across the stages of change for smoking, diet, exercise and stress management. RESULTS: After 12 months, patients of physicians in the intervention group did not show more movement through the stages of change for any of the behaviors than did patients of control physicians. Additionally, there were no differences between groups in counseling frequency, counseling intensity, or patient satisfaction with counseling. CONCLUSIONS: A high dropout rate at follow-up and resulting "power" problems limit the possible conclusions. The high numbers of patients in early stages of change and the minimal improvement over time underline the need for improving motivational counseling skills of primary care physicians in Germany. In our study the dissemination of these strategies failed. We offer lessons we feel can be learned from this outcome. Further studies should focus on ways to enhance the process of educating physicians for implementing counseling strategies in primary care settings.

[The Marburg questionnaire on habitual health findings--a study on patients with chronic pain]. / Marburger Fragebogen zum habituellen Wohlbefinden. Untersuchung an Patienten mit chronischem Schmerz.

BACKGROUND: Subjective well-being is an essential ingredient in the quality of life concept. The Marburg questionnaire, a seven item scale for the assessment of the trait dimension of well-being, claims to possess good psychometric properties. This is investigated in two studies with chronic pain patients. METHODS: The first study utilizing a prospective, randomized, and controlled design, served to find out the effects of a pain management program. Included were 236 patients with a diagnosis of chronic low back pain (Toronto classification) or tension type headache (IHS classification). Study 2 employed a cross-sectional design and relied on the data of 186 patients mainly with pain in the back and the head who had filled in a pain questionnaire provided by the Schmerztherapeutisches Kolloquium, a German pain society. RESULTS: Across the studies, internal consistency of the scale with Cronbach's alpha=0.91 proofed to be very satisfactory; retest-reliability after an interval of eight weeks came up to r(tt)=0.81. The scale is one dimensional and demonstrates good replicability of the dimensional structure. The factor accounts for 65% of the variance of the test scores. Moreover, the scale is sensitive to change, and, therefore, can be used as an assessment tool in interventions that aim at an improvement of well-being. Interrelations with variables indicating chronicity support the concept of construct validity. This refers to the stage algorithm provided by the pain clinic in Mainz, to the affective dimension of the pain experience, to disability, depression, and inability to work. CONCLUSION: The good psychometric quality of the questionnaire along with its brevity allows its application as part of a quality of life assessment.

Quality of life after cystectomy and urinary diversion: results of a retrospective interdisciplinary study.

PURPOSE: Now that creation of continent urinary reservoirs has become a standardized and clinically well established surgical technique with known morbidity and mortality rates, we reassessed the psychological and social aspects of this treatment compared with wet urostomy. MATERIALS AND METHODS: We developed a questionnaire (102 items) addressing general aspects of quality of life, disease related social support, coping strategies and stoma related issues. It was mailed to 600 patients with ileal conduits and 130 with continent reservoirs. Final analysis was restricted to 192 patients operated upon within the last 5 years (mean followup 2.7 years). RESULTS: The resulting groups were matched and paralleled regarding most treatment related and sociodemographic data. Final analysis did not reveal differences between the groups in disease related social support, coping strategies or quality of life when expressed as a total score. We found statistically significant superiority of continent reservoirs regarding all stoma related items, patient global self-assessment of their quality of life (single item, p < 0.005), physical strength, mental capacity, leisure time activities and social competence (p < 0.05). CONCLUSIONS: Continent diversion is clearly advantageous with respect to all items directly related to the stoma. The significant superiority of continent diversion in patient global self-assessment of their quality of life reflects the highly subjective dimension of the concept. Superiority in self-ratings of physical strength, mental capacity, leisure time activities and social competence could be interpreted as indicators of enhanced vitality in those patients, thus, supporting our understanding that women and men who actively participate in life have a special benefit from continent reservoirs.

[Do questionnaires for the assessment of change really assess change?]. / Messen Veränderungsfragebögen wirklich Veränderungen? Untersuchung zur Erfolgsbeurteilung in der psychologischen Schmerztherapie.

PROBLEM: Two methods for the assessment of change are evaluated: (1) subjects' ratings of the outcome taken after termination of the treatment, and (2) comparison of test scores taken before the beginning and after termination of the treatment. METHODS: Included in the analysis are 82 subjects with chronic headache and/or back pain who participated in psychological group treatment for pain. They were given an outcome rating scale with 15 items (ORS) after therapy in addition to pain diaries and questionnaires for the assessment of physical symptoms, mood and quality of life. Diaries and questionnaires were filled in twice, before and after therapy. RESULTS: The ORS demonstrates satisfying psychometric properties. Internal consistency is 0.94 (Cronbach's alpha) and retest reliability is 0.74. Correlations of this scale with outcome criteria based on pre-post comparisons, however, are mostly nonsignificant. Significant correlations are found when the ORS scores are related to the questionnaire scores after therapy. CONCLUSION: It is concluded that, contrary to the formulation of the items, the ORS scale does not so much assess change, but rather depicts the state of the subjects at the time the assessment is made.