[Acute inpatient multimodal pain therapy and rehabilitation: Framework conditions, tasks and differentiated patient allocation]. / Akutstationäre multimodale Schmerztherapie und Rehabilitation: Rahmenbedingungen, Aufgaben und differenzierte Patientenzuweisung.

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

[Multimodal pain therapy for treatment of chronic pain syndrome. Consensus paper of the ad hoc commission on multimodal interdisciplinary pain management of the German Pain Society on treatment contents]. / Multimodale Schmerztherapie für die Behandlung chronischer Schmerzsyndrome. Ein Konsensuspapier der Ad-hoc-Kommission Multimodale interdisziplinäre Schmerztherapie der Deutschen Schmerzgesellschaft zu den Behandlungsinhalten.

Multimodal pain management is a comprehensive treatment of complex chronic pain syndromes. In addition to medical therapy various other specialized therapeutic interventions based on the biopsychosocial model of pain origin and chronic pain development, are added. During the last few years treatment centers for chronic pain have been established throughout Germany. Multimodal pain management has been included in the official catalogue of the recognized medical procedures for day clinic units as well as for inpatient pain management. In daily practice there is, however, still a lack of clarity and of consistency about the components that multimodal pain management should contain. This is the reason for the ad hoc commission on multimodal interdisciplinary pain management of the German Pain Society to propose the following position paper that has been worked out in a multilevel and interdisciplinary consensus process. The paper describes the mandatory treatment measures in the four core disciplines of multimodal pain management, pain medicine, psychotherapy, exercise therapy including physiotherapy and assistant medical professions including nurses.

[Chronic pelvic pain]. / Chronischer Beckenbodenschmerz.

BACKGROUND: Chronic pelvic pain represents a multifactorial problem of unknown etiology. International standardized diagnostic and therapeutic approaches do not exist. METHODS: Medline and PubMed databases were searched for systematic reviews and guidelines for prevalence and therapy of chronic pelvic pain syndrome. RESULTS: Frequency, clinical picture, and treatment concepts for various forms of chronic pelvic pain are presented. If established treatments fail, then multimodal therapy concepts are recommended. Controlled studies, which fulfill evidence-based medicine criteria, are lacking. CONCLUSION: The success of multimodal therapeutic approaches in other chronic pain diseases should lead to the development and verification of these for chronic pelvic pain.

[Multidisciplinary assessment for multimodal pain therapy. Indications and range of performance]. / Interdisziplinäres Assessment zur multimodalen Schmerztherapie. Indikation und Leistungsumfang.

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

[Structure and process quality of multimodal pain therapy. Results of a survey of pain therapy clinics]. / Struktur- und Prozessqualität multimodaler Schmerztherapie. Ergebnisse einer Befragung von schmerztherapeutischen Einrichtungen.

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

Cluster headache and Alpha 1-antitrypsin deficiency.

Little is known about the pathophysiology of cluster headache (CH), one of the most debilitating primary headaches. Interestingly, associations of lung affecting diseases or lifestyle habits such as smoking and sleep apnoea syndrome and CH have been described. Certain genotypes for alpha 1-antitrypsin (alpha(1)-AT) are considered risk factors for emphysema. Our aim was to investigate possible associations between common genotypes of the SERPINA1 gene and CH. Our study included 55 CH patients and 55 controls. alpha(1)-AT levels in serum and the genotype were analysed. Patients CH characteristics were documented. We could not detect any association between CH and a genotype that does not match the homozygous wild type for alpha(1)-AT. Interestingly, there is a significant difference of CH attack frequency in patients who are heterozygous or homozygous M allele carriers. We conclude that the presence of an S or Z allele is associated with higher attack frequency in CH.

[Multimodal pain therapy: principles and indications]. / Multimodale Schmerztherapie: Konzepte und Indikation.

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

Placebo efficacy in childhood and adolescence migraine: an analysis of double-blind and placebo-controlled studies.

Studies on the treatment of migraine in children and adolescents are rare and difficult to design. In particular, the high placebo response in some trials makes it difficult to prove efficacy of a verum drug. We analysed all available placebo-controlled trials on acute and on prophylactic migraine treatment in children and adolescents with respect to different placebo rates (pain free and pain relief at 2 h; rate of responders with >or= 50% attack frequency decrease). We identified eight crossover and 11 parallel group trials on acute treatment. The placebo response rates were considerably lower in crossover trials than in parallel group trials (19.2% vs. 27.1% for pain free after 2 h and 39.4% vs. 56.9% for pain relief after 2 h). In the 10 prophylactic trials included in this analysis, only a small trend towards a lower placebo rate in crossover trials could be observed. Further significant factors associated with a lower placebo rate in childhood and adolescence trials on the acute treatment of migraine were single-centre (vs. multicentre) trials and small sample size. Age and sex were not associated with the placebo response. Our study suggests that parallel group trials on the acute treatment of migraine in children and adolescents show a very low therapeutic gain due to a high placebo rate. The verum response rates, however, are very similar to those seen in adulthood trials. In conclusion, trial designs on the acute and prophylactic treatment of migraine in children and adolescents should consider the specific findings of this analysis in order to exhibit a higher probability of showing significant differences between placebo and verum drug.

The incidence and prevalence of cluster headache: a meta-analysis of population-based studies.

Cluster headache is a trigemino-autonomic cephalgia with a low prevalence. Several population-based studies on its prevalence and incidence have been performed, but with different methodology resulting in different figures. We analysed all available population-based epidemiological studies on cluster headache and compared the data in a meta-analysis. The pooled data showed a lifetime prevalence of 124 per 100,000 [confidence interval (CI) 101, 151] and a 1-year prevalence of 53 per 100,000 (CI 26, 95). The overall sex ratio was 4.3 (male to female), it was higher in chronic cluster headache (15.0) compared with episodic cluster headache (3.8). The ratio of episodic vs. chronic cluster headache was 6.0. Our analysis revealed a relatively stable lifetime prevalence, which suggests that about one in 1000 people suffers from cluster headache, the prevalence being independent of the region of the population study. The sex ratio (male to female) is higher than published in several patient-based epidemiological studies.

[Pain therapy in addicted patients]. / Schmerztherapie bei suchtmittelabhängigen Patienten.

Each individual is entitled to an adequate and sufficient pain therapy. However, only a few studies have examined the peculiarities of pain management in drug-dependent or formerly addicted patients. Any addiction is disadvantageous for a successful pain therapy, since some of the prescribed drugs may themselves cause addiction. Drug-dependent patients are often tolerant to opioids. Additionally, there is a risk of iatrogenic pain becoming chronic due to disregard for already known risk factors and comorbidities. However, a history of addiction should not prevent sufficient pain therapy, especially since there is no risk of addiction when the pain therapy employed is adequate for the pathophysiology involved. There are adequate pain therapies for addicted patients. The best results are achieved by taking into account the physiological and psychological peculiarities of drug-dependent patients. Importantly, this should be combined with a variety of different, optimized, multimodal therapeutic regimes, as well as with an interdisciplinary approach.

[Requirements for an interdisciplinary lecture on pain. Results from a survey of medical students]. / Anforderungen an eine interdisziplinäre Schmerzvorlesung. Ergebnisse einer Umfrage unter Studierenden der Medizin.

BACKGROUND: Pain therapy is not an obligatory subject of undergraduate medical education in Germany. METHODS: In order to evaluate the expectations of undergraduate medical students regarding pain therapy as a lecture, a questionnaire was distributed to students visiting a faculty lecture on pain therapy. RESULTS: The main topics voted by the students as very interesting to them were pain syndromes such as low back pain, headache, and cancer pain. Furthermore, pharmacotherapy and the structure of pain therapy units were voted as interesting. Female students were significantly more interested in pain problems of specific patient groups (women, children, older patients, HIV-infected patients). Case reports on paper or with patient presentations were regarded as the most important didactic elements of such lectures. CONCLUSIONS: An analysis of the published undergraduate curricula in pain therapy revealed that the curriculum of the IASP and of the EFIC are too long and too theoretical, respectively. The curriculum of the DGSS meets many expectations of the students in this survey. Concepts of pain therapy education in undergraduate medical schools should consider the wishes of students regarding knowledge of pain syndromes and didactic methods.

[Psychosocial aspects of chronic low back pain]. / Pychosoziale Risikofaktoren in der Chronifizierung von Rückenschmerzen.

UNLABELLED: In many patients with chronic low back pain, no close correlation is found between the objective physical impairment and the subjective intensity of pain or the resulting disability. The process of chronification is the result of a complex interaction between somatic and psychosocial factors, as many epidemiologic and clinical studies could proof. DISCUSSION: Currently, these results are still neglected in clinical practise of diagnosis and therapeutic concepts.

Sumatriptan and ergotamine overuse and drug-induced headache: a clinicoepidemiologic study.

Drug-induced headache, particularly ergotamine-induced headache, is a common problem in migraine treatment. Some case reports suggest that even the new serotonergic antimigraine drugs such as sumatriptan can lead to overuse and subsequent drug-induced headache. We performed a controlled study to identify the rate of sumatriptan overuse and sumatriptan-induced headache and compared it to the rate of ergotamine overuse and ergotamine-induced headache. Two thousand sixty-five consecutive heachache patients, all experienced in intake of sumatriptan (n = 631) or ergotamine (n = 620), were enrolled over a three-year study period. The rates of overuse and drug-induced headache and the clinical features of the subgroups were compared. Risk factors for sumatriptan overuse were identified. The rates of ergotamine and sumatriptan overuse were 14.2% and 3.5%, respectively (p < 0.001). Drug-induced headache could be found more frequently in cases of ergotamine overuse than in cases of sumatriptan overuse (68% versus 32%; p < 0.01). Development of sumatriptan overuse was most common in patients with previous drug-induced headache (68%), combined headache as the primary headache type (45%), and subcutaneous application of sumatriptan (45%). We conclude that sumatriptan intake can lead to overuse and subsequent drug-induced headache. The risk for overuse and drug-induced headache is significantly lower than in patients with ergotamine intake. This might be caused in part by the relatively short period of sumatriptan availability on the market. The new generation of serotonin-1B/D-receptor agonists in the treatment of headache should have a potential for overuse similar to that of traditional headache drugs.

[Psychosocial handicap due to chronic headaches. Evaluation of the inventory of Disabilities caused by Headache]. / Psychosoziale Beeinträchtigung durch chronische Kopfschmerzen. Evaluation des Inventars zur Beeinträchtigung durch Kopfschmerzen (IBK).

Chronic primary headache has a considerable impact on the quality of life. To date, this impact has been evaluated by measurements of the general pain specific impairment of the quality of life. Headache specific measurements of quality of life or of disability caused by the headache are still missing for the German language. In America, a headache specific questionnaire, the "Headache Disability Inventory" (HDI), has been evaluated which is used in the presented study to create a German version, the "Inventar zur Beeinträchtigung durch Kopfschmerzen" (IBK). 94 consecutive patients with a primary headache disorder (59 female, 35 male; mean age 40 +/- 12 years) were examined. Cronbach's alpha was a = 0.90, the test-retest-reliability after three months was r = 0.87. An analysis of subscales for emotional and functional disability showed similar values for the internal consistency and the test-retest-reliability of these subscales. The scores of the different headache types did not differ significantly. In post-hoc-analyses, however, cluster headache showed higher disability scores than migraine both in the total scale and in the subscales. The total score of the IBK was significantly correlated with the number of headache days per month (r = 0.41; p < 0.0003) but not with the duration of disease or other demographic parameters. The IBK is the first German headache specific measurement of certain aspects of the quality of life in chronic headache patients. It can be used in clinical settings to evaluate the current state of the patient or to monitor treatment and it can be used for scientific studies.

Drug-induced headache: long-term results of stationary versus ambulatory withdrawal therapy.

Drug-induced headache is a well-known complication of the treatment of primary headache disorders, and its successful management is only possible by withdrawal therapy. However, it is unknown whether ambulatory or stationary withdrawal is the therapy preferred. We conducted a prospective study on the outcome of stationary versus ambulatory withdrawal therapy in patients with drug-induced headache according to the International Headache Society criteria. Out of 257 patients with the diagnosis of drug-induced headache during the study period, 101 patients (41 after ambulatory and 60 after stationary withdrawal therapy) could be followed up for 5.9 +/- 4.0 years. The total relapse rate after successful withdrawal therapy was 20.8% (14.6% after ambulatory and 25.0% after stationary withdrawal therapy, p < 0.2). The main risk factors for a relapse were male sex (OR = 3.9, CI = 1.3-11.6), intake of combined analgesic drugs (OR = 3.8, CI = 1.4-10.3), administration of naturopathy (OR = 6.0, CI = 1.2-29.3), and a trend to tension-type headache as the primary headache disorder (OR = 1.9, CI = 0.6-53.0). Our data suggest that neither the method of withdrawal therapy nor the kind of analgesic and other antimigraine drugs has a major impact on the long-term result after successful withdrawal therapy. Patients with risk factors according to our findings should be informed and monitored regularly, and combined drugs should be avoided. Furthermore, our data suggest that there is a need for research on individual psychological and behavioral risk factors for relapse after successful withdrawal therapy in drug-induced headache.