[Adaptive testing in rehabilitation: a way to economic assessment of patients' attributes]. / Adaptives Testen in der Rehabilitation - ein Weg zur ökonomischen Erhebung von Patientenmerkmalen*

For diagnostics and outcome measurement in clinical rehabilitation a multitude of questionnaires is used. In order to gain comparability of the diagnostic findings, generally, the same information is gathered of all patients, regardless of their state of health or how severely ill they are, by using identical groups of items. In this kind of assessment it is, however, problematic that (a) the assessment instrument usually only allows for adequate and reliable diagnostics of patients who suffer from injuries or illnesses of medium severity, and (b) that an uneconomic data collection is required because of an extensive set of items which may in individual cases be uninformative and unnecessary. This article shows how data assessment can be adjusted to the individual handicaps of the patient by using adaptive or tailored testing. Thus it can be ensured that the testing becomes more economical and results more precise. Furthermore, a high acceptance by the patients participating in the data collection can be achieved, as the test items submitted fit the ability of the patients adequately. Yet, adaptive test systems require a complex and very careful psychometrical development of the assessment procedure in such a way that in spite of presenting different items to patients, diagnostic outcomes are comparable between patients and for different points in time (e. g., pre-post comparison). This article shows the steps of development that have to be accomplished in order to set up a psychometrically sound adaptive test procedure. Moreover, it shows how its usage in the area of medical rehabilitation can be profitable for handlers and patients.

Religious commitment, religious coping and anxiety: a study in German patients with breast cancer.

Within the last few years the relationship between religiousness and psychosocial adjustment has become a subject of increasing interest. However, previous research did not explicitly differentiate between dispositional religious commitment and situation-specific religious coping. The current cross-sectional study investigated the relative power of religious commitment, positive and negative religious coping, and religious commitment x religious coping interactions in the prediction of anxiety. The sample consisted of 167 German breast cancer patients who were assessed during an inpatient rehabilitation programme. Results indicated that positive and negative religious coping were more strongly related to anxiety than dispositional religious commitment. Furthermore, hierarchical regression analysis revealed a religious commitment x negative religious coping interaction. According to this interaction, there seems to be some synergistic effect of high levels of religious commitment and high levels of negative religious coping. In contrast, positive religious coping did not function as a moderator and appeared to be closely related to religious commitment. This may be due to the specific religious-cultural background in Germany.

[Sensitivity to change of questionnaires measuring subjective health--results of a prospective comparative study]. / Anderungssensitivität von Fragebogen zur Erfassung der subjektiven Gesundheit--Ergebnisse einer prospektiven vergleichenden Studie.

PURPOSE: Questionnaires measuring patients' subjective health or health-related quality of life are indispensable tools for the evaluation of effects revealed by intervention studies in the field of medical rehabilitation. These patient-reported outcomes should appropriately reflect change over time. Unfortunately, "sensitivity to change" has so far not been adequately examined for German health-related quality of life questionnaires, especially not in a comparative way. Therefore, indices of sensitivity to change for three widespread generic assessment tools have been determined: IRES-3, SF-36, scales of the SCL-90-R. METHODS: A prospective comparative study was conducted in n = 1145 inpatients with orthopaedic/rheumatologic and cardiac diseases from 16 rehabilitation clinics. All patients received usual care. Their subjective health-status was assessed at two to four weeks before admission (t0), admission (t1), discharge (t2), and three months after discharge (t3). At each time point, they completed the IRES-3, SF-36, and relevant scales of the SCL-90-R. For the time interval t1-t2, Guyatt's responsiveness index (GRI) was calculated and compared across scales and instruments. RESULTS: Virtually all GRI coefficients for scales and aggregated scores, respectively, reached statistical significance. With respect to the GRI distributions of the diagnostic groups, most coefficients were located in a middle to upper range. While the results for the scales do not clearly indicate which assessment instrument should be preferred, GRI coefficients for higher aggregated scores suggest the IRES-3 to be most sensitive to change. CONCLUSION: These results can be helpful in selecting a health-related quality of life instrument or certain subscales for evaluation studies in the field of medical rehabilitation.

[Transfer of research findings into the practice of rehabilitation and effects on the development and stabilization of the infrastructure of rehabilitation sciences--the pension insurance perspective]. / Umsetzung von Forschungsergebnissen in die Rehabilitationspraxis und Effekte auf den Ausbau und die Stabilisierung der rehabilitationswissenschaftlichen Infrastruktur aus der Sicht der Rentenversicherung.

The programme for research in rehabilitation has been established by the Federal Ministry of Education and Research and the German Pension Insurance scheme in 1998 to further develop the methodology in this field. In addition to other effects, the large number of projects has strengthened the research structure in Germany. An important aim of the programme is the transfer of the research findings into the practice of rehabilitation. The initiators also organize this transformation process in terms of a long-term task. The paper describes the transfer of findings in the topics selected by the Pension Insurance scheme: patient education, access to rehabilitation, and vocational orientation in medical rehabilitation. Furthermore, additional activities concerning the transfer are outlined. To improve the practice of rehabilitation by transferring research findings is of great importance for the Pension Insurance scheme.

[Instruments for patient-reported outcomes and predictors in German-speaking rehabilitation research--current developments within the "Rehabilitation Sciences" research funding programme]. / Patientennahe Assessmentinstrumente in der deutschsprachigen Rehabilitationsforschung -- Aktuelle Entwicklungen aus dem Förderschwerpunkt "Rehabilitationswissenschaften".

In 1998, the German Federal Ministry of Education and Research (BMBF) and the German pension insurance scheme established a funding programme for research in rehabilitation. This initiative led to the establishment of eight regional research networks in which numerous research projects were sponsored for eight years (1998-2005). Within the framework of this funding programme, various self-assessment instruments were developed, adapted or improved in order to measure patient-reported outcomes and predictors. In sum, the analyses meet high psychometric standards. In this paper, a comprehensive review is given in five important assessment fields of rehabilitation research in Germany: Health-related quality of life (generic, disease-specific, children and adolescents, preference-based), evaluation of specific therapy and education programmes, motivation, screening for vocational problems and screening for comorbid mental disorders. The instruments are critically discussed, and perspectives for further research are pointed out.

[Regression to the mean]. / Regression zur Mitte.

The evaluation of rehabilitation programmes may be distorted by regression to the mean: In a group of patients with extreme measurement values, these values tend to be less extreme on a following point in time due to merely random components and regardless of a "true" treatment effect. If this effect is not taken into account the effectiveness of rehabilitation programmes may be estimated wrongly. In this paper regression to the mean is explained comprehensively, and common misunderstandings are clarified. It is shown which conditions are crucial for occurrence of regression to the mean and which factors determine its strength. Furthermore it is shown how regression to the mean should be controlled in repeated measurement designs.

[Sensitivity to change]. / Anderungssensitivität.

In rehabilitation research patient questionnaires are widely used for evaluative purposes, i. e. to measure improvements or deteriorations over time. This is only possible if the questionnaires applied appropriately reflect "true" change over time, i. e. they have to be sensitive to change. The aim of this paper is to point out the importance of the "sensitivity to change" concept for evaluative assessment tools and evaluative studies, respectively, considering quality of life research as an example. Various qualitative aspects, e. g. scaling of response options of assessment tools, are covered as well as quantitative methods, i. e. study designs and indices. Furthermore, recommendations for interpretation are given.

[The "rehabilitation sciences" research funding programme: research findings -- implementation -- impact and perspectives]. / Förderschwerpunkt "Rehabilitationswissenschaften": Ergebnisse -- Umsetzung -- Erfolge und Perspektiven.

In 1998, the German Federal Ministry of Education and Research (BMBF) and the German pension insurance scheme established a funding programme for research in rehabilitation. This "Rehabilitation Sciences" research funding programme comprises eight regional research networks for eight years in two periods (1998-2002, 2001-2005). In our paper we review the findings of the first funding period in five of the research fields: patient education, need for and access to rehabilitation, vocational training in medical rehabilitation to enhance return to work, comorbid mental disorders in patients with somatic diseases, and gender differences. Several activities aimed at transferring research findings into practice are outlined. Finally, the impact of the funding programme is summarized and perspectives for further funding are given.

[Goal oriented measurement with the IRES questionnaire: a critical interim statement]. / Zielorientierte Ergebnismessung (ZOE) mit dem IRES-Patientenfragebogen: Eine kritische Zwischenbilanz.

This paper gives a critical view on "Goal Oriented Measurement" (ZOE, Zielorientierte Ergebnismessung) with the IRES (Indicators of Rehabilitation Status) questionnaire. Gerdes (1998) proposed this method for individualizing outcome measurement in rehabilitation research. The rationale of Goal Oriented Measurement is described and differentiated from Goal Attainment Scaling and Patient Preferences. Subsequently, important shortcomings of Goal Oriented Measurement are pointed out: insufficient validity with regard to selecting clinically relevant problems, possible regression artifacts, unsuitably aggregated scores, possible reactivity, possible changes of individual problems, possible deteriorations in problems not initially selected, and plurality as well as small size of subsamples. Overall, Goal Oriented Measurement has to undergo substantial improvement.

13C isotopomer analysis of glucose and alanine metabolism reveals cytosolic pyruvate compartmentation as part of energy metabolism in astrocytes.

After incubation of glial cells with both (13)C-labeled and unlabeled glucose and alanine, (13)C isotopomer analysis indicates two cytosolic pyruvate compartments in astrocytes. One pyruvate pool is in an exchange equilibrium with exogenous alanine and preferentially synthesizes releasable lactate. The second pyruvate pool, which is of glycolytic origin, is more closely related to mitochondrial pyruvate, which is oxidized via tri carbonic acid (TCA) cycle activity. In order to provide 2-oxoglutarate as a substrate for cytosolic alanine aminotransferase, glycolytic activity is increased in the presence of exogenous alanine. Furthermore, in the presence of alanine, glutamate is accumulated in astrocytes without subsequent glutamine synthesis. We suggest that the conversion of alanine to releasable lactate proceeds at the expense of flux of glycolytic pyruvate through lactate dehydrogenase, which is used for ammonia fixation by alanine synthesis in the cytosol and for mitochondrial TCA cycle activity. In addition, an intracellular trafficking occurs between cytosol and mitochondria, by which these two cytosolic pyruvate pools are partly connected. Thus, exogenous alanine modifies astrocytic glucose metabolism for the synthesis of releasable lactate disconnected from glycolysis. The data are discussed in terms of astrocytic energy metabolism and the metabolic trafficking via a putative alanine-lactate shuttle between astrocytes and neurons.

Effects of ammonia exposition on glioma cells: changes in cell volume and organic osmolytes studied by diffusion-weighted and high-resolution NMR spectroscopy.

NH(4)Cl (10 mM) caused a sustained increase in the cell volume in immobilized, perfused F98 glioma cells to approx. 125% of control after 3 h, as measured by diffusion-weighted (1)H NMR spectroscopy. Concomitantly, the glutamine (Gln) concentration increased by 130%, accompanied by a marked decrease in cytosolic osmolytes, i.e. myo-inositol and taurine, determined from (1)H NMR spectra of PCA extracts. Inhibition of Gln synthetase partially prevented the increase in water content. While losses of organic osmolytes are also observed under hypotonic conditions, the rapid cell swelling is followed by the regulatory cell volume decrease (RVD), and is accompanied by decreased cytosolic Gln. We suggest that the rise in intracellular osmolarity, which is attributed to NH(4)Cl metabolism to Gln, but also to alanine (Ala), is not compensated by the release of other osmolytes, and causes cell swelling without RVD.

NMR spectroscopic study on the metabolic fate of [3-(13)C]alanine in astrocytes, neurons, and cocultures: implications for glia-neuron interactions in neurotransmitter metabolism.

Nuclear magnetic resonance (NMR) spectroscopy and biochemical assays were used to study the fate of [3-(13)C]alanine in astrocytes, neurons, and cocultures. (1)H- and (13)C-NMR analysis of the media demonstrated a high and comparable uptake of [3-(13)C]alanine by the cells. Thereafter, alanine is transaminated predominantly to [3-(13)C]pyruvate, from which the (13)C-label undergoes different metabolic pathways in astrocytes and neurons: Lactate is almost exclusively synthesized in astrocytes, while in neurons and cocultures labeled neurotransmitter amino acids are formed, i.e., glutamate and gamma-aminobutyric acid (GABA). A considerable contribution of the anaplerotic pathway is observed in cocultures, as concluded from the ratio (C-2-C-3)/C-4 of labeled glutamine. Analysis of the multiplet pattern of glutamate isotopomers indicates carbon scrambling through the TCA cycle and the use of alanine also as energy substrate in neurons. In cocultures, astrocyte-deduced lactate and unlabeled exogenous carbon substrates contribute to glutamate synthesis and dilute the [2-(13)C]acetyl-CoA pool by 30%. The coupling of neuronal activity with shuttling of tricarboxylic acid (TCA) cycle-derived metabolites between astrocytes and neurons is concluded from the use of [4-(13)C]-monolabeled glutamate leaving the first TCA cycle turn already for glutamine and GABA synthesis, as well as from the labeling pattern of extracellular glutamine. Further evidence of a metabolic interaction between astrocytes and neurons is obtained, as alanine serves as a carbon and nitrogen carrier through the synthesis and regulated release of lactate from astrocytes for use by neurons. Complementary to the glutamine-glutamate cycle in the brain, a lactate-alanine shuttle between astrocytes and neurons would account for the nitrogen exchange of the glutamatergic neurotransmitter cycle in mammalian brain.

[Effect strength variation in the single group pre-post study design: a critical review]. / Effektstärkevarianten beim Eingruppen-Prä-Post-Design: Eine kritische Betrachtung.

In Germany, studies in rehabilitation research--in particular evaluation studies and examinations of quality of outcome--have so far mostly been executed according to the uncontrolled one-group pre-post design. Assessment of outcome is usually made by comparing the pre- and post-treatment means of the outcome variables. The pre-post differences are checked, and in case of significance, the results are increasingly presented in form of effect sizes. For this reason, this contribution presents different effect size indices used for the one-group pre-post design--in spite of fundamental doubts which exist in relation to that design due to its limited internal validity. The numerator concerning all effect size indices of the one-group pre-post design is defined as difference between the pre- and post-treatment means, whereas there are different possibilities and recommendations with regard to the denominator and hence the standard deviation that serves as the basis for standardizing the difference of the means. Used above all are standardization oriented towards the standard deviation of the pre-treatment scores, standardization oriented towards the pooled standard deviation of the pre- and post-treatment scores, and standardization oriented towards the standard deviation of the pre-post differences. Two examples are given to demonstrate that the different modes of calculating effect size indices in the one-group pre-post design may lead to very different outcome patterns. Additionally, it is pointed out that effect sizes from the uncontrolled one-group pre-post design generally tend to be higher than effect sizes from studies conducted with control groups. Finally, the pros and cons of the different effect size indices are discussed and recommendations are given.

[Whole-body cryotherapy in rehabilitation of patients with rheumatoid diseases--pilot study]. / Die Bedeutung der Ganzkörperkältetherapie im Rahmen der Rehabilitation bei Patienten mit rheumatischen Erkrankungen.--Ergebnisse einer Pilotstudie.

UNLABELLED: Cryotherapy as a whole-body cold therapy (with cold air cooled by addition of nitrogen blown on the patients in an open cabin) for treatment of inflammatory rheumatic diseases already started in Bad Säckingen in 1986. In 1996, a new cold chamber (this time a closed chamber without any addition of nitrogen) based on compressor technology was introduced. The aim of our study was to test whether significant pain relief could be achieved by means of this cold therapy. Furthermore, we were interested in the practicability and acceptance of this new technique. Wellbeing during the treatment application and pain level were assessed using verbal and numerical rating scales. The sample consisted of 120 consecutive patients (75% women, age: 30-67 yrs, M = 52.6 yrs). These patients were suffering from primary fibromyalgia (40.7%), rheumatoid arthritis (17.3%), chronic low back pain (16.4%), ankylosing spondylitis (10.9%), osteoarthritis (9.1%), secondary fibromyalgia (3.6%) and other autoimmune diseases (1.8%) (mean duration of symptoms: 4 yrs). The patients were treated 2.5 minutes on average in the main chamber (mean temperature: -105 degrees C). The patients' statements concerning their pain level were analyzed by means of analyses of variance with repeated measures and paired-sample t-tests. RESULTS: The pain level after application of the cold therapy decreases significantly. The pain reduction lasts about 90 minutes. The initial pain level decreases during the whole time of treatment, no significant improvement, though, can be shown from the middle to the end of the four-weeks treatment. According to the results of our study, there is evidence that the whole-body cold therapy generates important short-term effects and somewhat weaker effects over the treatment period as a whole. Short-term pain reduction facilitates intensive application of physiotherapy and Occupational Therapy. The treatment procedure is practicable, and all in all well tolerated. From the patients' point of view, whole-body cold therapy is an essential part of the rehabilitation programme.

Multinuclear NMR spectroscopy studies on NH4Cl-induced metabolic alterations and detoxification processes in primary astrocytes and glioma cells.

Glutamine synthesis, the major pathway of ammonia detoxification, and the intracellular concentration of organic osmolytes in primary astrocytes and F98 glioma cells were investigated with multinuclear magnetic resonance spectroscopy. Acute exposure to ammonia (3 h incubation with NH4Cl) raised the concentration of glutamine and other amino acids, such as glutamate and aspartate, and decreased myo-inositol, hypotaurine, and taurine concentrations. The loss of these osmolytes was partially reversed by co-treatment with the glutamine synthetase inhibitor, methionine sulphoximine. Glutamate, the precursor of glutamine, is provided by stimulated anaplerotic flux via pyruvate carboxylase and glutamate dehydrogenase activity. Thus, the glutamine increase and myo-inositol decrease observed by in vivo magnetic resonance spectroscopy on patients with hepatic encephalopathy may be due to the disturbed osmoregulation in astrocytes caused by accumulation of glutamine and the subsequent loss of organic osmolytes.

[Freiburg/Bad Säckingen Scientific Rehabilitation Research Group]. / Rehabilitationswissenschaftlicher Forschungsverbund Freiburg/Bad Säckingen.

The Freiburg/Bad Säckingen Rehabilitation Research Network aims on problem solutions in rehabilitation in Germany. The core concept of the Research Group is "goal orientation in diagnosis, therapy and evaluation". This concept refers to both individual goals of patients and structural measures. The 13 projects of the Research Group deal with topics such as "specific communication problems in rehabilitation", "differential indication", "health economics", "methods", and "intervention and evaluation". To establish a long-term internal network in the Research Group and to facilitate intensive communication and co-operation between the various university-based and non-university-based institutions of rehabilitation in the Research Group area, Project Management and Methodological Support Offices were created.

[Religious dogmatism and ecclesiogenic neuroses. A quasi-experimental contribution to Catholic church communities between tradition and pleuralism]. / Kirchlicher Dogmatismus und ekklesiogene Neurosen. Ein quasiexperimenteller Beitrag über katholische Kirchengemeinden zwischen Tradition und Pluralisierung.

Schaetzing (1955) characterizes "ecclesiogen neurosis" as mental disturbances, which are caused by "dogmatism of the church". To prove his thesis that the factor "dogmatism of the church" goes along with ecclesiogen-neurotic symptoms we use as factorial levels two different forms of Catholic congregations, that is to say a "traditional congregation" (high "dogmatism of the church") and a "pluralistic" one (low "dogmatism of the church"). In this quasi-experimental design 93 Catholics who are involved in the church of a "traditional" congregation and 70 of a "pluralistic" one are examined. The correctness of categorizing these congregations to the factorial levels is proved empirically. To record ecclesiogen-neurotic symptoms we consider "religious anxiety" (Kim, 1988) and "depressivity" (Zerssen, 1976). Our findings show that active Catholics of both congregations show a distinct higher expressivity in the dependent variable "depressivity" compared with the mean population. The comparison of both congregation samples by analysis of covariance shows furthermore, that the dependent variable "religious anxiety" is significantly higher in the "traditional" congregation than in the "pluralistic" one. The results are later critically discussed.

The dangers of ill-health through recreation.

Healthy recreation for adolescents is discussed in its physical, psychological, educational and social dimensions. The medical and psychological dangers, in many current practices, are highlighted. Contemporary changes that have occurred in conceptions of pleasure and recreation are examined and the emerging evidence of the hazards involved is emphasised. Proposals for the prevention of these hazards to health are made.