[Organized pain management in the DRG reimbursement system]. / Organisierte Schmerztherapie im DRG-System.

Multidisciplinary pain management in pain centers can only be guaranteed if the DRG reimbursement system takes into account the multiple risk factors. The German pain associations prospectively analyzed clinical and administrative (DRG-related) data sets (n=3943) of inpatient and day care pain treatment facilities. The index diagnoses of 84% of the patient sample were grouped into nine basic DRGs. The most frequent pain procedure code was 8-918 ("multimodal pain management"). The minimal length of stay for this code set to 7 days was 17.2 days for the study sample. The DRG grouper software 2003 categorized 68.6% of the patients into PCCL 0 despite the proven complexity of risks and secondary diseases. The mean case weight in the sample was set at about 1. The pain-related data set analyzing pain severity, chronicity, and its influence on various functions emphasizes the total severity and burden of disease and thus the necessity for multimodal pain management. The German pain societies carried the motion that a new complex ICD code for chronic pain (with biopsychosocial consequences) should be established in the German Modification of the ICD. The new ICD code F62.80 and the procedure code 8-918 had not yet been implemented into the German DRG algorithm. Due to modifications in DRG systematics and the DRG algorithm, to be activated in 2005, the procedure code 8-918 will now automatically trigger into four special basic pain DRGs corresponding to the index pain diagnosis.

[Pain treatment yesterday--development of organized pain management]. / Schmerztherapie gestern--Entwicklung der organisierten Schmerztherapie.

This short historical report describes the course of development of interdisciplinary pain management starting from the early US-American pain clinics (nerve block clinics). The special developments in Germany are considered. The classification of pain treatment facilities is presented in detail. The change of paradigm from a biological (medical) pain model to a bio-psycho-social disease and pain concept implied abandoning monodisciplinary management strategies for chronic pain patients. Proved concerted actions regarding pain clinic organization and quality assurance are described.

[Development and evaluation of the multidimensional German pain questionnaire]. / Entwicklung und empirische Uberprüfung des Deutschen Schmerzfragebogens der DGSS.

The German pain questionnaire (DSF) has been developed and validated by the Task force on "Standardization and Economy in Pain Management" of the German Chapter of the International Association for the Study of Pain (DGSS). The concept of the DSF is based on a bio (medical) - psycho - social pain model. The modular approach to pain assessment consists of:demographic data,pain variables (e. g. pain sites, temporal characteristics, duration, intensity),pain associated symptoms,affective and sensory qualities of pain (adjective list by Geissner, SESCopyright ),pain relieving and intensifying factors,previous pain treatment procedures,pain-related disability (Pain Disability Index by Tait et al.),depression test CES-D (Center for Epidemiological Studies Depression Test),comorbid conditions,social factors (educational level, occupation, retirement status, compensation and/or litigation status, disability for work),health related quality of life (SF-36Copyright ). Practicability and content validity were tested in some 3000 patients. Comparison with external criteria (e. g. medical and psychiatric-psychological diagnoses, physician-determined chronicity of pain) proved good content validity and excellent reliability of patients statements in the questionnaire. The great majority of patients stated that the DSF covered their pain history completely and in an orderly fashion. Difficulty to answer the questions was considered low. The German pain questionnaire is a reliable and valid instrument for recording the multidimensional experience of pain. Data from such questionnaires are indispensable for follow-up studies and internal and external quality assessments. The DSF can be ordered from the German Society for the Study of Pain (www.dgss.org) and is a core instrument of the computer program "quality assurance in pain management" (QUAST) of this society.

[Health-related quality of life in patients with chronic pain]. / Gesundheitsbezogene Lebensqualität bei Patienten mit chronischen Schmerzen.

AIMS: An empirical comparison of the performance characteristics of 3 generic health-related quality of life (HRQL) measures in pain patients. METHODS: The Nottingham Health Profile (NHP), the Medical Outcomes Study 36-item Short-Form Health Survey (SF-36), and the German Life Satisfaction Scale (FLZ-M) by Henrich et al. were simultaneously employed in a multicenter survey measuring the impact of pain on quality of life. The HRQL- instruments were incorporated into the German Pain Questionnaire (pain variables, CES-D, Pain Disability Index). RESULTS: Characteristics of 3294 pain patients of 13 pain facilities are detailed in tables 1-3. Six of the 8 SF-36- and 4 of the 6 NHP-scales show satisfactory item-total correlations, bottom- and ceiling-effects, and internal consistency. FLZ-M reliabilities are satisfactory. The item weighting procedure of the FLZ-M proves to be unnecessary. Principle component analyses result in 7 factors for the SF-36 and the NHP. Six of the SF-36-factors are fairly homogeneous. The heterogeneity of the NHP- factors is marked. Correlations of the HRQL scales with depression (CES-D), anxiety (STAI) and physical functioning (FFbH-R-18) are high in all related contents. All instruments discriminate well between headache and back pain patients, between several pain grades (v. Korff) and the 3 Mainz pain chronicity stages. CONCLUSIONS: The SF-36 has satisfactory to good psychometric properties in pain patients, the NHP item selection has to be improved. The FLZ-M weighting can be eliminated. The shortcomings of the SF-36 can be overcome by adding short scales on role functioning and pain (modular approach).

Cross-validation of the SCL-27: a short psychometric screening instrument for chronic pain patients.

We constructed a short multidimensional screening instrument for chronic pain patients based on the items contained in the Symptom Check List-90-Revised (SCL-90-R). The proposed dimensional structure of the SCL-90-R was recently shown to be irreproducible in chronic pain patients. As a consequence, the use of the Global Severity Index (GSI) was recommended, although it did not capture all information contained in the many items of the SCL-90-R. Based on an exploratory factor analysis, a six-dimensional structure using 27 items from the SCL-90-R was explored utilizing the data of 2780 chronic pain patients. A short form was prospectively tested on 581 patients in the same setting. Criteria for item selection were high convergent and low discriminant correlations. The assessment of the dimensions was kept short, but a minimum of four items were retained. A questionnaire yielding the dimensions (I) depressive symptoms, (II) dysthymic symptoms, (III) vegetative symptoms, (IV) agoraphobic symptoms, (V) symptoms of social phobia, and (VI) symptoms of mistrust was obtained. Additionally, the GSI of the SCL-90-R could be estimated precisely (r =0.96). The SCL-27 can be used for screening psychopathology in chronic pain patients. The scoring algorithm of the SCL-27 can be used for the 90-item form as well.

[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.

The symptom check-list, SCL-90-R: its use and characteristics in chronic pain patients.

The SCL-90-R is a widely-used questionnaire for self-report of psychological distress and multiple aspects of psychopathology, as part of the evaluation of chronic pain patients and other non-psychiatric populations. The aim of this study is the presentation of clinical results of this multidimensional questionnaire in a convenience sample of 3540 chronic pain patients treated in a multidisciplinary pain centre. Confirmatory Factor Analysis (CFA), Exploratory Factor Analysis (EFA), single scale factor analyses and Cronbach's alphas are used to assess the internal structure and correlation to other instruments (CES-D, STAI, MPSS) to assess construct validity. It is shown that the 9 dimensions postulated by Derogatis et al. (1977 a) cannot at all be distinguished in chronic pain patients. The use of single subscores of the SCL-90-R, often employed as a screening instrument for specific diagnoses, such as depression, is at least questionable in chronic pain patients.

No changes in mood with the seasons: observations in 3000 chronic pain patients.

OBJECTIVE: Seasonal affective disorder (SAD) and the theory of the effect of light on depression have gained some popularity in recent years. Research on epidemiology is largely based on retrospective measures asking explicitly for the experience of seasonal variations. Those measures have a low positive predictive value and do not enable us to distinguish between experience and belief. METHOD: A consecutive sample of chronic pain patients filled out a depression questionnaire (CES-D) routinely as part of the diagnostic interview on becoming in-patients at a Pain Clinic in Mainz during a 5-year period. RESULTS: No support for seasonality or light effects was found. CONCLUSION: The effect of light on depression or seasonality may be smaller than expected in general. SAD as a true disorder is probably rare.

[Assessing disability in chronic pain patients.]. / Behinderungseinschätzung bei chronischen Schmerzpatienten.

Despite its importance for chronic pain diseases, pain-related disability is a poorly defined concept with theoretical deficits. The distinction between impairment, disability, and handicap proposed by the WHO is an important contribution to clarification of the disability construct. With reference to four criteria (underlying disability construct, degree of behaviour generalization, assessment mode, scope) different assessment procedures of pain-related disability are presented and the advantages and disadvantages of each are discussed. A multidimensional approach to pain-related disability is advocated. Diagnostic information yielded by different assessment procedures should be viewed as complementary rather than as exclusive data sources. A German version of a self-report instrument (Pain Disability Index) that assesses disability in chronic pain patients is presented. The results from four data sets concerning different aspects of reliability and validity confirm the good psychometric properties of the instrument. The instrument can be used in chronic pain research as well as in clinical contexts. It is recommended that subjective disability data be complemented by behavioral observation and additional data sources (e.g. assessment of disability by the spouse/partner).

Median nerve blockade during diagnostic intravenous regional anesthesia as measured by somatosensory evoked potentials.

Intravenous regional anesthesia (IVRA) may be used as a diagnostic method in patients suffering from chronic pain in the forearm or hand to differentiate the origin of pain within the anesthetic area from that above. For this purpose it needs to be proven that all nerve fibers are blocked and that conduction blockade induced by IVRA takes place within the nerve trunks. Therefore the transmission of impulses in a nerve trunk to the central nervous system has been studied. Diagnostic intravenous regional anesthesia (5 mg/kg mepivacaine 1%) of the arm was performed in eight patients for 30 min. Short-latency somatosensory evoked potentials (SSEPs) induced by median nerve stimulation at the wrist were recorded from the scalp at 5-min intervals before, during, and after IVRA. In five patients, sensory nerve action potentials (SNAPs) of the median nerve, at the elbow and axilla, and SSEPs at spinous processus C-7 were recorded simultaneously. During IVRA the function of the nerve fibers which are assumed to mediate pain was tested by the patient's sensation following median nerve stimulation at an intensity which evoked pain before IVRA. During IVRA, peak latencies of the scalp recorded SSEPs (N20) increased progressively and interpeak amplitudes (N20/P25) decreased. After 20 min, SSEPs could no longer be recorded, and median nerve stimulation no longer evoked any sensation at all. After deflation of the cuff, both peak latency (N20) and interpeak amplitude (N20/P25) of SSEPs recovered. The changes in latency and amplitude of SSEPs from the scalp as well as SNAPs and SSEPs from the neck were similar. Because SSEPs, SNAPs, and the pain sensation following median nerve stimulation disappeared during IVRA, it may be concluded that the thick and thin myelinated nerve fibers of the median nerve have been blocked. For diagnostic use, IVRA is superior to peripheral nerve blockade, which has been shown previously to not abolish SSEPs.

[The course of pain with electronic diaries, real time measurements and time series analysis]. / Schmerzverlauf mit elektronischen Tagebüchern, Realzeitmessungen und Zeitreihenanalysen.

Important physiological parameters such as blood pressure, ECG and others are measured today on a continuous basis or at fixed intervals and are documented together with the date and the time. Individual results and subjective data are ascertained through questioning the patient, observation or patient's self-assessment and are documented with paper and pencil, without having any certainty of the exact time of ascertainment or that such is comprehensible. Battery-operated microcomputers have been developed in the form of electronic diaries (E.D.) for patients. Upon emitting an auditory signal, the questions appear in the computer display, and the questions are then correspondingly answered by the patient. These answers are fed to the permanent data store and are transferred on-line and processed at a later time in a PC. The time and data of the entries are simultaneously registered and are included in the complete document when it is later printed out. A capacity of 64 kbytes suffices to accommodate the data collected; likewise, the battery is sufficient for constant use. The entries are made as categorical data or numerically. Free-style entries are not possible. With the aid of a specially-developed program, the courses of a chronic pain syndrome in patients with degenerative joint diseases were studied. The percentage change in the pain course, benefit risk considerations, prognoses with the aid of sequential analyses and plausibility criteria can be calculated from the data. The advantages of this new instrument are its simple handling and reliable functioning. Its disadvantage is that it lacks the possibility to allow free-style entries.(ABSTRACT TRUNCATED AT 250 WORDS)

[Real time collection of pain profile in treatment with ibuprofen]. / Realzeiterfasste Schmerzzeitprofile unter der Behandlung mit Ibuprofen.

In an open three-center pilot study, 17 patients suffering from chronic persistent pain syndrome, due to osteoarthritis of the hip and knee or spondylarthrosis, were treated orally with 1800-2400 mg Ibuprofen per day for 3 weeks. The chronic pain syndrome and joint status were assessed by the physician at the beginning, and after 7, 14 and 21 days. Self-assessments were made by the patients six times daily during the full study period by means of battery-driven electronic diaries (E.D.). The data entered by the patients were stored in the E.D. and after online transfer, processed and evaluated in a PC using appropriate software programs. E.D. were returned by 16 of 17 patients for evaluation. The technical functioning of the instrument was perfect; its use was accepted by patients and physicians. The closely-meshed real-time recording of pain course and other subjective data, such as adverse events or medication, etc., enables the physician to calculate more exactly and reliably improvement rates, as well as to carry out prognostic trend analyses and individual benefit-risk-ratio estimates. By comparing different kinds of data, each entered at the same time, plausibility checks are possible. The procedure presented here is considered to be a new valuable tool for reviewing subjective data from clinical drug trials.

High spinal anesthesia does not depress central nervous system function as measured by central conduction time and somatosensory evoked potentials.

Short-latency somatosensory evoked potentials (SSEPs) in response to median nerve stimulation were recorded from the neck and the scalp before and during diagnostic high spinal anesthesia (touch T3, pinprick C8) in six patients with chronic pain. The central conduction time--the time difference between the neck-recorded N13 and the scalp-recorded N20--and the amplitudes of the SSEPs did not change in a statistically significant way during high spinal anesthesia. However, latencies of the neck-recorded N13 and the scalp-recorded N20 and P25 increased slightly. This may have been due to a local anesthetic effect on those spinal roots of the median nerve in which segmental pinprick analgesia occurred. Because high spinal anesthesia did not depress central nervous function, as measured by central conduction time, and SSEP amplitudes, it is concluded that scalp-recorded SSEPs during high spinal anesthesia measure the effects of local anesthetics in the cerebrospinal fluid on neuronal pathways outside the brain.

Spinal cord transmission of impulses during high spinal anesthesia as measured by cortical evoked potentials.

Cortical evoked potentials (CEPs) resulting from posterior tibial nerve stimulation could be recorded before, but not during, diagnostic high spinal anesthesia to T2-3 in six patients with chronic pain. In contrast, spinal cord stimulation at T8-9 during high spinal anesthesia resulted in CEPs with reduced peak amplitudes and increased P1 and N2 latencies. Amplitudes of the CEPs evoked by spinal cord stimulation increased with increases in stimulus intensity before and during high spinal anesthesia (N = 3). During spinal anesthesia, higher stimulus intensities were required to evoke CEPs of similar amplitudes as before. Because CEPs evoked by stimulation of the posterior tibial nerve disappeared, but those evoked by spinal cord stimulation did not, it is concluded that spinal anesthesia is a result of blockade of nerve roots, not blockade of neural transmission within the cord. Therefore, diagnostic high spinal anesthesia cannot exclude an origin of pain within the spinal cord.

Vitamin status of inpatients with chronic cephalgia and dysfunction pain syndrome and effects of a vitamin supplementation.

66 female inpatients with dysfunction pain syndrome, chronic cephalgia and facial pain participated in a randomized, placebo-controlled double-blind study, half the patients receiving a multivitamin preparation for 12 days and the other half a placebo. The biochemically determined vitamin status at the start of the study revealed gaps in the coverage of the vitamin supply, particularly with regard to the vitamins thiamin, riboflavin and folic acid. 65% of the patients showed a subclinical vitamin deficiency of two or more vitamins. With regard to the development of pain during the study no statistically significant differences could be determined, however, between the active-treatment and placebo groups. Nevertheless, a clear reduction in pain was more frequently observed in the active-treatment group, and a deterioration of pain more frequently in the placebo group. A reduction in pain was reported more often by patients in whom the values of alpha-ETK, alpha-EGOT, folic acid and cyanocobalamin improved in the course of the study. Vitamin administration in physiological doses evidently have only weak effects on the behavior of pain; analgesic vitamin effects may be presumed in the case of correspondingly high therapeutic doses for a prolonged period.

Sacroiliac joint arthrodesis for chronic lower back pain.

We report our experience with sacroiliac joint arthrodesis in cases of overt osteoarthritis. Twenty-two operations were performed over a period of 3.5 years and reviewed between 12 and 55 months postoperatively. The clinical picture and diagnostic steps are discussed. We conclude that if the selection of patients is strict we can expect 70% satisfactory results.

Pyrazolone drugs and their use at pain centres.

In multidisciplinary pain centres, comparatively little use is made of analgesic agents. The applications and limitations of analgesic drug therapy are discussed, in comparison with other therapeutic modalities.

A pilot study of the value of ceramics for bone replacement.

We report on eight cases in which ceramic implants were used to replace bone grafts. The results of this pilot study show definite usefulness of tricalcium phosphates, whereas hydroxyapatite did not prove suitable.