The CUPCIG (CAM-Use in Primary Care in Germany) Study:Part I-Pain. Study Protocol of a Pilot-trial to Assess Feasibility, Acceptability and Perceived Effectiveness of CAM in Pain Disorders in Primary Care.

BACKGROUND: There is limited valid data available on CAM procedures for chronic joint and neuropathic pain in primary care in Germany. Indiviual CAM qualifications of the general practitioners (GPs) and the potential of cost reduction through CAM treatment are almost unknown. The aim of this pilot trial preceding the main study is to examine the survey mode, to estimate the response rate by GPs with or without an additional qualification for CAM, and to identify the status quo in therapeutic approaches for chronic pain disorders in primary care. METHODS: This is a cross-sectional study with an ex post facto design among German GPs consisting of 2 parts: In a first step, a pilot trial precedes the main study targeting 200 GPs with and 200 GPs without additional qualification in CAM in a selected region. RESULTS: The results of the CUPCIG study comprise the distribution of pain types treated in primary care practices, the GPs' attitude toward complementary pain therapy, pharmacological or CAM treatment, the estimate of cost reduction through CAM treatment of pain, the application of diverse CAM procedures, and biographical data. DISCUSSION: The CUPCIG study serves to compile pain therapy approaches in primary care in Germany with respect to the individual CAM expertise of the GPs.

Globalised world, globalised diseases: A case report on an amoebiasis-associated colon perforation.

In 2010 the World Health Organisation estimated the number of infections with Entamoeba histolytica at about 50 million cases including 100000 fatal courses. In most cases this infection is a subclinical event with few or none symptoms noticeable for the patient. Courses of this disease and incidence of this parasite in industrialised nations are not yet fully investigated. Our case reports about a 68-year-old male patient from Turkey who lives for more than 30 years in Germany and had not been abroad during the past 2 years. Resistant asymptomatic amoebic dormant bodies caused an emergency-laparoscopy and revealed the seldom complication of a colon perforation. In the age of globalisation all providers in the health care systems are urged to acquaint themselves also with non-typical syndromes for the countries they work in order to reduce preventable morbidity respectively mortality rates.

A comparison of Kneipp hydrotherapy with conventional physiotherapy in the treatment of osteoarthritis: a pilot trial.

BACKGROUND: An increasingly aging population implies an increasing prevalence of osteoarthritis (OA) of hip or knee. It has been ascertained that unspecific hydrotherapy of OA according to Sebastian Kneipp not only improves the range of mobility but also reduces pain significantly and increases the quality of life of the patients affected. OBJECTIVE: The main aim of this pilot study was to determine the effects of hydrotherapy in comparison to conventional physiotherapy, and to analyze the feasibility of the study design under clinical circumstances. DESIGN, SETTING, PARTICIPANTS AND INTERVENTIONS: The study design is a prospective randomized controlled three-arm clinical pilot trial, carried out at a specialist clinic for integrative medicine. Thirty patients diagnosed with symptomatic OA of hip or knee and radiologic findings were randomly assigned to one of two intervention groups and a control group: hydrotherapy (group 1), physiotherapy (group 2), and both physiotherapy and hydrotherapy (group 3, control group) of the affected joint. PRIMARY OUTCOME: pain intensity of the affected joint in the course of inpatient treatment; secondary outcome: health-related quality of life, joint-specific pain and mobility in the course of the study. RESULTS: Concerning the main outcome, intervention group 1 showed most beneficial effects in the course of inpatient treatment, followed by groups 3 and 2, and also the indirect flexion ability of hip or knee together with the general patient mobility through the "timed up and go" test were mainly improved within group 1 followed by groups 3 and 2. CONCLUSION: The results of this pilot study demonstrate beneficial effects of hydrotherapy. The study design is feasible. For statistically significant evidence and a robust conclusion of efficacy of Kneipp's hydrotherapy, a larger sample size is necessary. TRIAL REGISTRATION NUMBER: NCT 00950326.

Intravenous vitamin C in the treatment of shingles: results of a multicenter prospective cohort study.

BACKGROUND: Vitamin C is an immune-relevant micronutrient, which is depleted in viral infections and this deficiency seems to play a critical role in the pathogenesis of herpes infections and in the development of postherpetic neuralgia. The objective of this observational multicenter study was to evaluate the utilization, safety and efficacy of intravenously administrated vitamin C in patients with shingles. MATERIAL/METHODS: Between April 2009 and December 2010 16 general practitioners recorded data of 67 participants with symptomatic herpes zoster who received vitamin C intravenously (Pascorbin® 7.5 g/50 ml) for approximately 2 weeks in addition to standard treatment. The assessment of pain (VAS) and the dermatologic symptoms of shingles such as hemorrhagic lesions and the number of efflorescences were investigated in a follow-up observation phase of up to 12 weeks. RESULTS: Mean declines of pain scores (VAS), number of affected dermatomes and efflorescences, and the presence of hemorrhagic vesicles between the baseline and follow-up assessments at 2 and 12 weeks were statistically significant. Overall, 6.4% of the participants experienced post-herpetic neuralgia. Common complaints such as general fatigue and impaired concentration also improved during the study. The effects and the tolerability of the treatment were evaluated positively by the physicians. The risk of developing PHN was reduced. CONCLUSIONS: The data presented here provide evidence that concomitant use of intravenously administered ascorbic acid may have beneficial effects on herpes zoster-associated pain, dermatologic findings and accompanying common complaints. To confirm our findings, randomized, placebo-controlled clinical studies are necessary.

[Inpatient treatment for postradical neck pain syndrome by use of complementary medicine]. / Stationäre naturheilkundliche Therapie eines chronischen, postoperativen Schmerzsyndroms nach Neck-Dissection.

INTRODUCTION: The standard treatment of papillary thyroid cancer with a diameter >1 cm is thyroidectomy combined with a modified neck-dissection of the central (perithyroideal, prelaryngeal and tracheo-esophageal) lymph nodes and a consecutive radiation. Frequently, postoperative pain syndromes occur after this procedure. The so-called 'postradical neck pain syndrome' (PRNS) is a combination of cervical neuropathic pain, constricted and painful mobility of the shoulder region(s) including inhibited abduction capacity of the shoulder joint and a scapula alata. PRNS is often resistant to conventional therapy such as analgesics and physiotherapy. CASE REPORT: A 56-year-old female inpatient, suffering from a severe PRNS after thyroidectomy and neck dissection due to papillary thyroid cancer for the past 2 years, was treated with a combination of hydrotherapy according to Kneipp, conventional physiotherapy, acupuncture and cantharidin blisters in order to reduce neuropathic pain, increase the range of cervical mobility and improve parameters of health-related quality of life (based on SF-36). RESULTS: Within 4 weeks of combined treatment, the left-cervical neuropathic pain was improved remarkably, and the range of the cervical mobility was increased sufficiently. In addition, the SF-36 scales 'pain' and 'common well-being' were improved to a clinically relevant extent. The multi-modular treatment was well tolerated. CONCLUSIONS: In PRNS, a combination of several methods of complementary medicine may be an effective and well tolerated alternative to conventional treatment. Further clinical studies are required to confirm the results.

Intravenous administration of vitamin C in the treatment of herpetic neuralgia: two case reports.

BACKGROUND: Acute herpetic neuralgia (AHN) due to a reactivated varicella zoster virus infection is a common problem. Furthermore, about 18% of all patients with confirmed herpes zoster (HZ) develop postherpetic neuralgia (PHN). The leading factors of the prognosis and persistence of symptoms are patient age and the size of the lesions. Animal studies came to a similar conclusions that in both AHN and PHN, inflammatory cytokines such as IL-6 and IL-8 could serve as predictive markers and that a positive influence of vitamin C administration, by modifying cytokine metabolism, could be demonstrated. CASE REPORT: Two patients (females aged 67 and 53 years) from an average and unselected patient group of a general practice with confirmed AHN were observed in the course of their illness. They received the basic analgesic (according to the WHO step scheme) and viral-static therapy. Furthermore, 15 g of vitamin C was administered intravenously every second day over a period of two weeks. Sudden and total remission of the neuropathic pain (measured on the basis of the visual analogous-scale, VAS) could be observed. Remission of the cutaneous lesions was noted within 10 days. CONCLUSIONS: The use of the vitamin C appears to be an interesting component of alternative therapeutic strategies in the treatment of HZ. Especially for therapy-resistant cases of PHN, vitamin C administration should be examined as an additional option. To test and confirm the clinical findings, randomized clinical studies concerning the use of vitamin C in the concomitant treatment of zoster-associated neuralgia should be performed.

A comparison of Kneipp hydrotherapy with conventional physiotherapy in the treatment of osteoarthritis of the hip or knee: protocol of a prospective randomised controlled clinical trial.

BACKGROUND: The increasing age of the population, especially in the western world, means that the prevalence of osteoarthritis is also increasing, with corresponding socioeconomic consequences. Although there is no curative intervention at present, in accordance with US and European guidelines, pharmacotherapeutic and non-pharmacological approaches aim at pain control and the reduction of functional restriction.It has been established that hydrotherapy for osteoarthritis of the hip or knee joint using serial cold and warm water stimulation not only improves the range of movement but also reduces pain significantly and increases quality of life over a period of up to three months. Weight reduction is important for patients with osteoarthritis of the hip or knee. In addition, conventional physiotherapy and exercise therapy have both been shown, at a high level of evidence, to be cost-effective and to have long-term benefits for pain relief, movement in the affected joint, and patient quality of life. METHODS/DESIGN: The study design consists of a prospective randomised controlled three-armed clinical trial, which will be carried out at a specialist clinic for integrative medicine, to investigate the clinical effects of hydrotherapy on osteoarthritis of the knee or hip joint, in comparison with conventional physiotherapy.One hundred and eighty patients diagnosed with osteoarthritis of hip or knee will be randomly assigned to one of three intervention groups: hydrotherapy, physiotherapy, and both physiotherapy and hydrotherapy of the affected joint. In the first group, patients will receive Kneipp hydrotherapy daily, with water applied in the form of alternate cold and warm thigh affusions (alternating cold and warm water stimulation is particularly relevant to the knee and hip regions).Patients in the second group will receive physiotherapy of the hip or knee joint three times a week. Patients in the physiotherapy-hydrotherapy combination group will receive both joint-specific physiotherapy three times a week and alternate cold and warm thigh affusions every day. Follow-up assessments will be on three levels: clinical assessment by the investigator; subjective patient assessment consisting of a patient diary, and questionnaires on admission and at the end of the treatment phase; and a final telephone assessment by the external evaluation centre. Assessments will be made at baseline, after two weeks of inpatient treatment, and finally after a further ten weeks of follow-up. The primary outcome measure will be pain intensity of the affected joint in the course of inpatient treatment, judged by the patient and the investigator. Secondary outcomes include health-related quality of life and joint-specific pain and mobility in the course of the study. Statistical analysis of the results will be on an intention-to-treat basis. CONCLUSION: This study methodology has been conceived according to the standards of the CONSORT recommendations. The results will contribute to establishing hydrotherapy as a non-invasive, non-interventional, reasonably priced, therapeutic option with few side effects, in the concomitant treatment of osteoarthritis of the hip or knee. TRIAL REGISTRATION NUMBER: NCT 00950326.

[Inpatient treatment for CRPS I by use of complementary medicine]. / Stationare, naturheilkundliche Therapie eines komplexen regionalen Schmerzsyndroms (CRPS I).

INTRODUCTION: Complex regional pain syndromes (CRPS) are mainly characterized by a burning, intense spontaneous pain,mechanical allodynia of the affected limb, disorders of the skin,local hyperhidrosis, lymphedema as well as trophic disorders of the skin, bones and joints. The overall clinical appearance is dominated by a dysfunction of the sympathetic nervous system. One dominant etiological hypothesis is that major mechanisms for CRPS symptoms, which might be present during the course of CRPS, are trauma-related cytokine release, exaggerated neurogenic inflammation, sympathetically maintained pain, and cortical reorganization in response to chronic pain. CASE REPORT: We report the case of a 33-year-old female patient who suffered from a CRPS type I (cold type) of the left foot which had been traumatically induced 9 months before. The patient presented with a severe pain syndrome, an allodynia of the dermatomes L5 and S1 left with significant trophic skin disturbances, followed by a lymphedema and a malposition (pronation) of the left dorsum pedis. METHODS: In the course of a 10-week in-house treatment the patient received a multidisciplinary therapy-management based on complementary medicine with intensive use of hydrotherapy according to Kneipp, and physiotherapy. RESULTS: Pain intensity over treatment decreased from 8 (initial) to 2 (after 8 weeks) ona 10-point numeric rating scale. Furthermore, local symptoms of the left foot, i.e. hyperhidrosis, trophic skin disorders and lymphedema decreased significantly. CONCLUSIONS: Therapeutic strategies derived from complementary medicine may be an effective approach to the complex treatment of CRPS. Their effects should be further investigated in controlled clinical trials.

[Treatment of a radiculopathia by whole-body hyperthermia]. / Behandlung einer Radikulopathie bei ossärer Metastasierung der Lendenwirbelsäule durch Infrarot-A-Ganzkörperhyperthermie.

INTRODUCTION: Cancer metastases can be the reason of neuropathic pain. It can be caused by infiltration and compression of nerves. Cytokines released by tumor cells and the affected nerve structures induce an inflammatory reaction that enhances the neuropathic pain. CASE REPORT: We report the case of a 67-year-old female patient. She suffered from a persisting and acutely exacerbated radiculopathy (L5/S1 right) due to metastases of breast cancer (pT1bL0N1R1G2M1/osseous; ER 95%, PR 95%, Her2-new-score 3+) in the lumbar spine. Traditional treatments had failed to yield sufficient therapeutic effects. METHODS: We performed 6 sessions of water-filtered infrared-A whole-body hyperthermia using a commercial system (Iratherm 1000; Von Ardenne Institute for Applied Medical Research, Dresden, Germany). The wave-length was 600-1300 nm, the aimed body core temperature was 38.5 degrees C. The intensity of pain was assessed by visual analog scale. RESULTS: Pain intensity (VAS) decreased from 9 (initial) to 3 points after the first 3 treatment sessions. The patient was completely free of pain after 6 sessions. No side-effects were observed. At follow up after 3 and 24 weeks the patient was still free of pain. CONCLUSION: Infrared-A whole-body hyperthermia might be an effective therapeutic procedure with rare side-effects for tumor-induced neuropathic pain. Its use should be investigated further in controlled clinical trials.