[Structural change as an outcome paradigm in psychodynamic psychotherapy - results of the PAL-Study (long-term psychoanalytic psychotherapy study]. / Umstrukturierung als Ergebnisparadigma der psychodynamischen Psychotherapie - Ergebnisse aus der Praxisstudie Analytische Langzeittherapie.

OBJECTIVE: Psychodynamic psychotherapies have proved to lead to relevant symptomatic improvement. An unresolved question, however, is what amount of psychodynamic change can be expected beyond symptom relief. For theoretical and methodological reasons rooted in the psychodynamic approach, this question has been difficult to answer until now. METHOD: In the German study PAL (long-term psychoanalytic psychotherapy), 32 patients in psychoanalytic therapy and 27 patients in psychodynamic psychotherapy were studied from the perspective of therapists, patients and researchers through three years post-treatment. In this paper we study the aspect of psychodynamic change of dysfunctional relations, unconscious conflicts and structural aspects as diagnosed by the Operationalized Psychodynamic Diagnostic method. Structural change is rated by the Heidelberg Structural Change Scale. RESULTS: A comparison of the two forms of therapy shows more structural change in long-term psychoanalytic psychotherapy compared to the shorter psychodynamic psychotherapy. A comparison of patients with a high level and a low level of structural change revealed that the highly changed patients showed greater symptom relief and greater satisfaction with therapy, and that their therapists perceived a better overall result of treatment. DISCUSSION: For psychodynamic psychotherapies structural change seems to be a relevant paradigm of outcome in addition to symptom relief. In longer and more frequent psychoanalytic therapies more structural change occurs compared to shorter psychodynamic psychotherapies. Beside the amount and length of treatment, the different therapy targets - working through vs. supportive - seem to be important.

Structural change as a predictor of long-term follow-up outcome.

Based on data from psychoanalytic long-term psychotherapies, the predictive value of three measures of pre-post change for retrospective patient assessments of outcome at 1-year and 3-year follow-up was investigated. Pre-post changes were measured using the Global Severity Index (GSI), the Inventory of Interpersonal Problems (IIP) total score, and the Heidelberg Structural Change Scale (HSCS). In line with psychoanalytic theory, it was assumed that structural changes cause especially persistent changes and would, therefore, be most suitable to predict the follow-up criterion. This expectation was confirmed: Pre-post changes in GSI and IIP were only weakly associated with assessments at 1-year follow-up and not at all with assessments at 3-year follow-up. In contrast, correlations between changes in HSCS and outcome assessments were highly significant at both occasions.

Noninvasive three-dimensional assessment of femoroacetabular impingement.

A CT-based method ("HipMotion") for the noninvasive three-dimensional assessment of femoroacetabular impingement (FAI) was developed, validated, and applied in a clinical pilot study. The method allows for the anatomically based calculation of hip range of motion (ROM), the exact location of the impingement zone, and the simulation of quantified surgical maneuvers for FAI. The accuracy of HipMotion was 0.7 +/- 3.1 degrees in a plastic bone setup and -5.0 +/- 5.6 degrees in a cadaver setup. Reliability and reproducibility were excellent [intraclass correlation coefficient (ICC) > 0.87] for all measures except external rotation (ICC = 0.48). The normal ROM was determined from a cohort of 150 patients and was compared to 31 consecutive hips with FAI. Patients with FAI had a significantly decreased flexion, internal rotation, and abduction in comparison to normal hips (p < 0.001). Normal hip flexion and internal rotation are generally overestimated in a number of orthopedic textbooks. HipMotion is a useful tool for further assessment of impinging hips and for appropriate planning of the necessary amount of surgical intervention, which represents the basis for future computer-assisted treatment of FAI with less invasive surgical approaches, such as hip arthroscopy.

Accuracy and potential pitfalls of fluoroscopy-guided acetabular cup placement.

Using a total of 30 cadaveric hips, the accuracy of a fluoroscopy-based computer navigation system for cup placement in total hip arthroplasty (THA) was investigated and an error analysis was carried out. The accuracy of placing the acetabular component within a predefined safe zone using computer guidance was compared to the precision that could be achieved with a freehand approach. Accurate control measurements of the implanted cup were obtained using fiducial-based matching to a pre-operative CT scan with respect to the anterior pelvic plane. A significantly higher number of cups were placed in the safe zone with the help of the navigation system. The variability of cup placement could be reduced for cup abduction but not substantially for cup version. An error analysis of inaccurate landmark reconstruction revealed that the registration of the mid-pubic point with fluoroscopy was a potential source of error. Keeping this pitfall in mind, fluoroscopy-based navigation in THA is a useful tool for registration of the pelvic coordinate system, particularly those points that cannot be reached by direct pointer digitization with the patient in the lateral decubitus position.