Comprehensive assessments and related interventions to enhance the long-term outcomes of child, adolescent and young adult cancer survivors - presentation of the CARE for CAYA-Program study protocol and associated literature review.

BACKGROUND: Improved, multimodal treatment strategies have been shown to increase cure rates in cancer patients. Those who survive cancer as a child, adolescent or young adult (CAYA), are at a higher risk for therapy-, or disease-related, late or long-term effects. The CARE for CAYA-Program has been developed to comprehensively assess any potential future problems, to offer need-based preventative interventions and thus to improve long-term outcomes in this particularly vulnerable population. METHODS: The trial is designed as an adaptive trial with an annual comprehensive assessment followed by needs stratified, modular interventions, currently including physical activity, nutrition and psycho-oncology, all aimed at improving the lifestyle and/or the psychosocial situation of the patients. Patients, aged 15-39 years old, with a prior cancer diagnosis, who have completed tumour therapy and are in follow-up care, and who are tumour free, will be included. At baseline (and subsequently on an annual basis) the current medical and psychosocial situation and lifestyle of the participants will be assessed using a survey compiled of various validated questionnaires (e.g. EORTC QLQ C30, NCCN distress thermometer, PHQ-4, BSA, nutrition protocol) and objective parameters (e.g. BMI, WHR, co-morbidities like hyperlipidaemia, hypertension, diabetes), followed by basic care (psychological and lifestyle consultation). Depending on their needs, CAYAs will be allocated to preventative interventions in the above-mentioned modules over a 12-month period. After 1 year, the assessment will be repeated, and further interventions may be applied as needed. During the initial trial phase, the efficacy of this approach will be compared to standard care (waiting list with intervention in the following year) in a randomized study. During this phase, 530 CAYAs will be included and 320 eligible CAYAs who are willing to participate in the interventions will be randomly allocated to an intervention. Overall, 1500 CAYAs will be included and assessed. The programme is financed by the innovation fund of the German Federal Joint Committee and will be conducted at 14 German sites. Recruitment began in January 2018. DISCUSSION: CAYAs are at high risk for long-term sequelae. Providing structured interventions to improve lifestyle and psychological situation may counteract against these risk factors. The programme serves to establish uniform regular comprehensive assessments and need-based interventions to improve long-term outcome in CAYA survivors. TRIAL REGISTRATION: Registered at the German Clinical Trial Register (ID: DRKS00012504, registration date: 19th January 2018).

Factors associated with smoking cessation in patients with coronary heart disease: a cohort analysis of the German subset of EuroAspire IV survey.

BACKGROUND: Tobacco smoking is one of the most important risk factors of coronary heart disease (CHD). Hence, smoking cessation is considered pivotal in the prevention of CHD. The current study aimed to evaluate smoking cessation patterns and determine factors associated with smoking cessation in patients with established CHD. METHODS: The fourth European Survey of Cardiovascular Disease Prevention and Diabetes investigated quality of CHD care in 24 countries across Europe in 2012/13. In the German subset, smoking cessation patterns and clinical characteristics were repetitively assessed a) during index event due to CHD by medical record abstraction, b) as part of a face-to-face interview 6 to 36 months after the index event (i.e. baseline visit), and c) by telephone-based follow-up interview two years after the baseline visit. Logistic regression analysis was performed to search for factors determining smoking status at the time of the telephone interview. RESULTS: Out of 469 participants available for follow-up, 104 (22.2%) had been classified as current smokers at the index event. Of those, 65 patients (62.5%) had quit smoking at the time of the telephone interview, i.e., after a median observation period of 3.5 years (quartiles 3.0, 4.1). Depressed mood at baseline visit and higher education level were less prevalent amongst quitters vs non-quitters (17.2% vs 35.9%, p = 0.03 and 15.4% vs 33.3%, p = 0.03), cardiac rehabilitation programs were more frequently attended by quitters (83.1% vs 48.7%, p < 0.001), and there was a trend for a higher prevalence of diabetes at baseline visit in quitters (37.5% vs 20.5%, p = 0.07). In the final multivariable model, cardiac rehabilitation was associated with smoking cessation (OR 5.19; 95%CI 1.87 to 14.46; p = 0.002). DISCUSSION: Attending a cardiac rehabilitation program after a cardiovascular event was associated with smoking cessation supporting its use as a platform for smoking cessation counseling and relapse prevention.

Evaluation of a self-management patient education programme for fibromyalgia-results of a cluster-RCT in inpatient rehabilitation.

The objective was to evaluate the effectiveness of a self-management patient education programme for fibromyalgia syndrome (FMS) as compared with usual care education in inpatient rehabilitation. In a multicentre cluster-randomized controlled trial, 583 inpatients in 3 rehabilitation centres received an advanced self-management patient education programme or usual care education. Patients completed questionnaires at admission, discharge and after 6 and 12 months. Primary outcomes were disease- and treatment-specific knowledge at discharge, and self-management-competencies after 6 months. Secondary outcomes included satisfaction, attitudes, coping competencies, psychological distress and health impairment. We found a medium-sized effect on disease- and treatment-specific knowledge at discharge (P < 0.05, Cohen's d = 0.45, 95% CI = 0.27-0.63), and small effects for subjective knowledge, pain-related control, self-monitoring and insight, communication about disease, action planning for physical activity and treatment satisfaction (all P < 0.05). Only the effect on knowledge persisted for 6 and 12 months. This advanced education programme seemed to be more effective in the short term than usual education. However, intermediate- and long-term effects did not emerge. While superior long-term effects on knowledge as well as short-term effects on self-management skills may suggest implementation, additional long-term effects on other patient-relevant outcomes would be desirable. Trial registration: German Clinical Trials Register, DRKS00008782, Registered 8 July 2015.

One in two cancer patients is significantly distressed: Prevalence and indicators of distress.

OBJECTIVE: Psychological distress is common in cancer patients, and awareness of its indicators is essential. We aimed to assess the prevalence of psychological distress and to identify problems indicative of high distress. METHODS: We used the distress thermometer (DT) and its 34-item problem list to measure psychological distress in 3724 cancer patients (mean age 58 years; 57% women) across major tumor entities, enrolled in an epidemiological multicenter study. To identify distress-related problems, we conducted monothetic analyses. RESULTS: We found high levels of psychological distress (DT ≥ 5) in 52% of patients. The most prevalent problems were fatigue (56%), sleep problems (51%), and problems getting around (47%). Sadness, fatigue, and sleep problems were most strongly associated with the presence of other problems. High distress was present in 81.4% of patients reporting all 3 of these problems (DT M = 6.4). When analyzing only the subset of physical problems, fatigue, problems getting around, and indigestion showed the strongest association with the remaining problems and 76.3% of patients with all 3 problems were highly distressed (DT M = 6.1). CONCLUSIONS: Our results show a high prevalence of psychological distress in cancer patients, as well as a set of problems that indicate the likely presence of other problems and high distress and can help clinicians identify distressed patients even if no routine distress screening is available.

Self-management education for rehabilitation inpatients suffering from inflammatory bowel disease: a cluster-randomized controlled trial.

Although inflammatory bowel disease (IBD) affects patients' psychological well-being, previous educational programs have failed to demonstrate effects on psychosocial outcomes and quality of life. Therefore, we developed a group-based psychoeducational program that combined provision of both medical information and psychological self-management skills, delivered in an interactive manner, and evaluated it in a large, cluster-randomized trial. We assigned 540 rehabilitation inpatients suffering from IBD (mean age 43 years, 66% female) to either the new intervention or a control group comprising the same overall intensity and the same medical information, but only general psychosocial information. The primary outcome was patient-reported IBD-related concerns. Secondary outcomes included disease knowledge, coping, self-management skills, fear of progression, anxiety, depression and quality of life. Assessments took place at baseline, end of rehabilitation and after 3 and 12 months.The psychoeducational self-management program did not prove superior to the control group regarding primary and secondary outcomes. However, positive changes over time occurred in both groups regarding most outcomes. The superior effectiveness of the newly developed psychoeducational program could not be demonstrated. Since the intervention and control groups may have been too similar, this trial may have been too conservative to produce between-group effects.

[Acceptance of the Implementation of Standardised Patient Education Programmes by the Multidisciplinary Rehabilitation Team Using the Example of a Back School - A Qualitative Study]. / Akzeptanz der Einführung standardisierter Patientenschulungen durch das multidisziplinäre Reha-Team am Beispiel einer Rückenschule - Eine qualitative Studie.

AIM: The transfer of standardised patient education programmes into practice is a complex process with a multitude of influencing factors. Determinants relate among others to the organisation and individuals (e. g., practitioner, patient). Knowledge about individual factors regarding the trainers of patient education programmes in the German rehabilitation system is scarce. The aim of this study is to explore the acceptance of trainers concerning the implementation of a standardised back school and to derive facilitators and barriers to the implementation of patient education programmes. METHODS: Semi-structured guideline-based interviews were conducted in 10 rehabilitation clinics. The sample consisted of 46 trainers (25 women): 11 physicians, 11 psychologists, 21 physio-/exercise therapists and 3 occupational therapists with a mean age of 41. The opinions of the trainers regarding the central components of back schools in general, their opinions about the new curriculum, their expectations on its implementation, anticipated difficulties with implementation and requests to the project team were explored as indicators for acceptance. The data were analysed with a multi-step qualitative content analysis. RESULTS: 6 main categories comprising 136 subcategories were created and 729 quotations coded. Regarding the central components that should be covered by back schools, back-friendly behaviour was addressed most often. Opinions regarding the new curriculum were mostly positive. Trainers' approval of content and methods was highlighted and the similarity with existing offers in the clinics as well as the structure of the programme were rated positively. The trainers expected an increased patient orientation and personal development as well as a common, coherent language and interdisciplinarity. Difficulties were anticipated regarding time and personnel as well as therapy and appointment planning and also regarding the motivation/acceptance of patients. A wish for communication, education of trainers and feedback was directed at the project team. CONCLUSION: The study demonstrates high acceptance of programme implementation and central components of modern patient education programmes among trainers. The basis of individual facilitators and barriers has been investigated and might contribute to further development of implementation interventions. Communication and education considering those factors play a central role.

[The Impact of 2 Interventions on Implementation Fidelity of a Standardized Back School Program in Inpatient Orthopedic Rehabilitation Facilities]. / Der Einfluss von 2 Implementierungsinterventionen auf die Implementierungsgüte einer standardisierten Rückenschulung in der orthopädischen Rehabilitation.

STUDY OBJECTIVE: Evaluation of the effectiveness of 2 implementation interventions - train-the-trainer workshops (TTT) and written implementation guideline (GL) - in terms of implementation fidelity of a back-training school within inpatient orthopedic rehabilitation. METHODS: An implementation trial was conducted using a mixed-methods approach for outcome evaluation in 10 rehabilitation clinics randomly assigned to the interventions. Data were assessed by questionnaires and observation forms. RESULTS: Trainers in the TTT condition, as compared to trainers in the GL condition, rated both their patient-oriented back school practice (d=1.37) and achievement of manual-based educational goals (W=0.18) significantly higher. Patients in the TTT condition showed significantly higher treatment satisfaction compared to patients in the GL condition (d=0.44). There were no significant group effects regarding the observed fidelity. CONCLUSIONS: An interactive TTT showed several benefits with regard to subjective outcomes compared to a written guideline.

[Empowerment by patient education in rheumatology]. / Empowerment durch Patientenschulung in der Rheumatologie.

Due to the chronic course, rheumatic diseases may be associated with both long-lasting pain and movement limitations. Those afflicted by these disorders thus face continuous challenges regarding both adapting to their illness as well as changing their lifestyle habits, for example increasing the physical activity levels. However, patient education may provide patients with the competencies they need to cope with their illness and modify their behavior. Therefore, patient education programs are core elements of rehabilitation in rheumatology. The German Society for Rheumatology has performed pioneering work concerning conceptualization and evaluation of standardized educational programs. In this article some more recent developments and up to date standards for contents and didactics of self-management programs are presented. Empowerment may be considered the overriding aim of these programs, i.e. enabling patients to make informed decisions in situations where their health is involved. Patient-centered didactic methods as used in state of the art concepts mirror the empowerment approach. To foster sustainability of lifestyle changes, detailed planning of behavioral modifications is recommended, thus increasing the chance of transferring changes adopted during rehabilitation into everyday living. Such methods have been proven to be effective and are employed in the updated education concept for patients with fibromyalgia syndrome, which is described here as an example. The Centre for Patient Education offers support in updating and evaluating patient education concepts.

[Development of a Set of Rehabilitation Related Multiple-choice-questions in Medical Education]. / Entwicklung eines Prüfungsfragenpools für die rehabilitationsbezogene Lehre im Studiengang Humanmedizin.

In the rehabilitation related teaching as in other subjects of the medical training multiple choice (MC) examinations are the most frequent type of examinations. Compared to other subjects only a few MC questions are available for the interdisciplinary subject Rehabilitation. Therefore an internet-based online platform "Pool of rehabilitation related MC questions" was developed to assist teachers regarding the provision, design and organization of high-quality rehabilitation related MC questions. A total of 502 existing MC questions were collected from 12 German Medical Faculties. After removal of 59 questions not suitable for formal and content reasons a total of 443 questions were presented to 6 reviewers for triple reviews (a total of 1 329 expert reviews received). Of the 502 questions 335 (67%) were included in the final pool including short cases with 46 case studies. The questions refer to the following learning objectives: principles of rehabilitation (40%), rehabilitative interventions (20%), diagnosis and assessment (18%), initiation and control of the rehabilitation process (12%) and methods/quality of rehabilitative interventions (10%). The use of the online platform modules resp. the questions are for free for lecturers. This includes the compilation and output of complete examinations, the statistical evaluation, and other audit-related materials. This examination pool counteracts the current lack of quality-assured rehabilitation-related MC questions and contributes to set common standards for the Medical Faculties to rehabilitation related examinations.

Measurement of stable changes of self-management skills after rehabilitation: a latent state-trait analysis of the Health Education Impact Questionnaire (heiQ™).

PURPOSE: To assess stable effects of self-management programs, measurement instruments should primarily capture the attributes of interest, for example, the self-management skills of the measured persons. However, measurements of psychological constructs are always influenced by both aspects of the situation (states) and aspects of the person (traits). This study tests whether the Health Education Impact Questionnaire (heiQ™), an instrument assessing a wide range of proximal outcomes of self-management programs, is primarily influenced by person factors instead of situational factors. Furthermore, measurement invariance over time, changes in traits and predictors of change for each heiQ™ scale were examined. METHODS: Subjects were N = 580 patients with rheumatism, asthma, orthopedic conditions or inflammatory bowel disease, who filled out the heiQ™ at the beginning, the end of and 3 months after a disease-specific inpatient rehabilitation program in Germany. Structural equation modeling techniques were used to estimate latent trait-change models and test for measurement invariance in each heiQ™ scale. Coefficients of consistency, occasion specificity and reliability were computed. RESULTS: All scales showed scalar invariance over time. Reliability coefficients were high (0.80-0.94), and consistency coefficients (0.49-0.79) were always substantially higher than occasion specificity coefficients (0.14-0.38), indicating that the heiQ™ scales primarily capture person factors. Trait-changes with small to medium effect sizes were shown in five scales and were affected by sex, age and diagnostic group. CONCLUSION: The heiQ™ can be used to assess stable effects in important outcomes of self-management programs over time, e.g., changes in self-management skills or emotional well-being.

[Depressivity as mediator in the fear-avoidance model: a path analysis investigation of patients with chronic back pain]. / Depressivität als Mediator im Angst-Vermeidungs-Modell : Eine pfadanalytische Untersuchung an Patienten mit chronischen Rückenschmerzen.

INTRODUCTION: The fear-avoidance model (FAM) has gained widespread acceptance as a conceptual framework predicting chronic pain development. However, there is still a high amount of unexplained variance in the prediction of outcome variables. This study aimed to test depression as a mediator of prospective links between the FAM variables pain intensity, pain-related fear, avoidance behavior and disability in order to achieve a better prediction of model variables. MATERIAL AND METHODS: Single mediation analyses were conducted using path analysis of longitudinal data from patients with chronic back pain (n = 243). RESULTS: There was at least partial mediation by depression for all prospective relations of FAM variables analyzed. The mediation effects increased the percentage of explained variance of the predicted model variables. CONCLUSION: The findings provide support for additional consideration of depressive symptoms to obtain a better understanding of prospective associations between FAM variables. The findings indicate that in the treatment of chronic back pain following a multiple target approach to reduce pain, pain-related fear and avoidance behavior and also depressive symptoms should be considered.

[Medical rehabilitation group-programmes concerning health promotion, patient education and psychoeducation - a 2010 national survey]. / Gruppenprogramme der Gesundheitsbildung, Patienten-schulung und Psychoedukation in der medizinischen Rehabilitation 2010 - Eine Bestandsaufnahme.

OBJECTIVE: High quality demands are being placed on concepts of educational group programmes in medical rehabilitation as well as the related trainer qualifications. A nationwide survey of German medical rehabilitation clinics in 2005 had revealed a need for improving educational practice according to these quality criteria. An updated investigation was performed in 2010 aiming at describing group programmes used in medical rehabilitation. METHOD: 1 473 inpatient and outpatient medical rehabilitation clinics were invited to participate. 908 clinics reported on their training programmes. Data from clinics caring for patients with somatic disorders could be compared to the 2005 survey. Data from clinics for both psychosomatic and substance abuse disorders was collected for the first time in 2010. RESULTS: Overall, psychologists and physicians were reported to be the most frequent conductors of educative programmes. In somatic clinics, psychologists, dieticians and occupational therapists or physiotherapists were the most common conductors. Two-thirds of the institutions reported no training prerequisites for staff members to perform patient education. 80% of the education programmes were categorized post hoc into 3 classes: "generic health education", "disorder-specific patient education", and "psychoeducational group programmes". Almost two-thirds of all programmes were carried out with 8-15 participants, and many used several interactive didactic methods. Programmes conducted in small groups (<8 participants) used significantly more interactive methods than those conducted in larger groups did (>15 participants). Only half of the programmes were manualized. Significantly more interactive methods were used in completely manualized programmes. Only about half of the programmes were evaluated, and only very few evaluation studies were published. The institutions wished additional support by workshops especially concerning qualification of their staff and concerning educational concepts. CONCLUSIONS: A need for further improvement and support exists relative to the training of educators and the development of manuals as well as evaluation and publication of the programmes.

[Development and short-term effects of a standardized patient education program for in-patient cardiologic rehabilitation]. / Entwicklung und kurzfristige Effektivität eines standardisierten Schulungsprogramms für die Rehabilitation bei koronarer Herzkrankheit.

BACKGROUND: Patient education is an essential part in the treatment of coronary heart disease in medical rehabilitation. In the German-speaking area, no standardized and evaluated patient education program for coronary heart disease is available so far. In this paper, we demonstrate the development of a quality assured patient education program based on a health-education program of the German statutory pension insurance scheme. METHODS: In a multi-level approach, an existing program was modified concerning treatment evidence, practical guidelines, theories of health and illness behavior and quality criteria for patient education as well as clinical experience and thereafter manualized. In a formative evaluation, feasibility and patient acceptance of this modified program were assessed using evaluation questionnaires of patients and trainers. Afterwards, effects of the patient education program as compared to a traditional education program were assessed on a short-term (at discharge), medium-term (6-month follow-up) and long-term (12-month follow-up) basis in a multicenter quasi-experimental control group study of patients with coronary heart disease (n=434). RESULTS: Results of the formative evaluation demonstrate an overall good acceptance and a good feasibility of the manualized program. Short-term results show a significant small treatment effect in the primary outcome variable patients' knowledge (p=0.001, η2 =0.028). Furthermore, small effects were also observed among some secondary outcomes, such as attitude towards medication, planning of physical activity, psychological quality of life and satisfaction with the education program. CONCLUSION: A standardized education program for patients with coronary heart disease has been developed in a systematic process based on established quality standards. Depending on the outstanding medium and long-term effects, the program may be recommended for general use in medical rehabilitation. The manual provides the prerequisites allowing for a successful transfer into clinical practice.

[Patient-centered communication in the physician-patient relationship]. / Patientenorientierte Kommunikation in der Arzt-Patient-Beziehung.

As a result of increasing demands for more patient-centeredness in the German health care system, physician-patient communication has been subject to transformation. Physicians are being requested to take into account their patients' communicative needs, including information, shared decision making, and emotional support, more vigorously than they had been in the past. A cooperative model of the physician-patient relationship is considered most suitable for fulfilling these needs and for empowering patients to make informed decisions regarding their own health care. However, a large body of evidence exists-particularly regarding communication between cancer patients and their doctors-that shows that patients' needs are not adequately addressed or met. This potential for optimization is all the more important because targeting patients' needs during doctor-patient communication not only improves patients' satisfaction with the communication, quality of life, and well-being, but may also produce better treatment outcomes.

[Psychosocial issues of long-term cancer survivors]. / Psychosoziale Folgen bei Langzeitüberlebenden einer Krebserkrankung.

Although cancer incidence rates are increasing, recent statistical studies suggest that cancer patients are showing higher cure rates as well as improved overall survival rates for most cancer locations. These advances are explained by improved strategies in early diagnoses as well as improved cancer therapies. Therefore, the number of long-term cancer survivors has also increased, but only few studies, especially within the last years, have focused on psychosocial issues of this subgroup. Some studies show that overall quality of life of long-term cancer survivors is quite high and comparable to that of the normal population. Nevertheless, a substantial percentage of former patients shows reduced quality of life and suffers from various sequelae of cancer and its treatment. This review focuses on the most common psychosocial issue of long-term survivors such as reduced psychological wellbeing, neuropsychological deficits and cancer-related fatigue syndrome. Finally, recommendations for problem-oriented interventions as well as improvement of psychosocial care of long-term survivors are given.

[The German version of parents' postoperative pain measure (PPPM-D). Validation on children 2-12 years old]. / Die deutsche Version des Parents' Postoperative Pain Measure (PPPM-D). Validierung an Kindern im Alter von 2 bis 12 Jahren.

BACKGROUND: Parents become increasingly more responsible for the postoperative pain management of their children. Useful and valid pain assessments for parents may improve pain measurement. The aim of this study was to evaluate a German version of the parents' postoperative pain measure (PPPM-D). METHODS: After translation of the PPPM into German 52 children between 2 and 12 years of age, undergoing orthopedic and trauma surgery, were included in a prospective study. At least one of the parents completed the PPPM-D on the preoperative day and the day of surgery until postoperative day 5. Both, the children's and infants postoperative pain scale (CHIPPS) for children between 2 and 4 years and the faces pain scale revised (FPS-R) for children between 5 and 12 years were also assessed. Moreover, the acceptance of the PPPM-D by the parents was assessed. RESULTS: The PPPM-D showed satisfactory reliability (Cronbach's α values = 0.77-0.87). Construct validity was demonstrated with strong correlations with the CHIPPS and the FPS-R. Discriminative validity was shown by both statistically and clinically significant differences between minor, medial and major surgeries on the first 3 days after surgery. The examination of sensitivity to change yielded promising results. The PPPM-D was well accepted by the participating parents. CONCLUSIONS: The results of this study provide evidence of the reliability, validity and high acceptance of the PPPM-D as an assessment tool of postoperative pain among children aged 2 through to 12 years of age after orthopedic or trauma surgery.

[DGRW-update: patient education]. / DGRW-Update: Patientenschulung.

Patient education programmes, i. e. standardized, manualized, interactive group programmes aiming to increase self-management and empowerment, are a core element of medical rehabilitation for chronic conditions. In an update of the evidence of the effectiveness of patient education, its effectiveness was proven for a broad spectrum of chronic disorders, such as diabetes mellitus, chronic low back pain, rheumatoid arthritis, coronary heart disease, chronic heart failure, bronchial asthma, COPD, and cancer, as well as for the modification of health behaviours, such as diet and exercise. To sustain effects, aftercare interventions, such as support provided by phone, were found to be successful. Interventions targeted to particular patient groups according to gender, age, or migration background are also being developed more frequently. When evaluating educational interventions not only distal outcomes, such as quality of life and participation, should be used but also proximal outcomes such as self-management skills. A recent survey of patient education practice in medical rehabilitation revealed a continuing potential for optimization relative to manualization, evaluation and didactics. However, the dissemination of innovative programmes into rehabilitation routine presents a major challenge.

[Innovative concepts for patient education in medical rehabilitation]. / Innovative Schulungskonzepte in der medizinischen Rehabilitation.

Patient education aims to empower rehabilitants. While patient education has, in the past, been conceived of as providing solely information, modern self-management concepts now focus on both behavioral competencies and motivational factors. Participants receive all the skills and tools necessary to make informed decisions regarding both their health and lifestyles and to actively participate in the rehabilitation process. Accordingly, didactic methods have changed from predominantly vertical lectures to more patient-oriented and interactive approaches. Meta-analyses have proven that patient education is effective in improving the chronic conditions of patients. However, the implementation of modern concepts into routine care is still suboptimal. The Center of Patient Education, funded by the German Statutory Pension Insurance, has performed a survey of the present state of patient education within medical rehabilitation programs in Germany. Furthermore, quality criteria for patient education have been developed, an internet database presenting self-management programs in a systematic manner has been created, and various services designed to improve educational practice are being offered by the Center of Patient Education. Lastly, a state-of-the-art, self-management education program is described.

[Elevated postoperative pain levels following orthopedic surgery. Depression as a strong predictor]. / Erhöhter postoperativer Schmerz nach orthopädischen Operationen. Depression als starker Prädiktor.

The aim of this study was to examine whether depression is a strong predictor of elevated postoperative pain levels following orthopedic surgery and whether the implementation of standardized pain management is more beneficial for patients with depression. We performed a non-randomized, prospective study with two different groups of patients who underwent orthopedic surgery. Group 1 (n=249) received non-standardized pain therapy whereas group 2 (n = 243) was treated with a standardized pain management concept. Effects of the treatment were monitored with a VAS-based pain assessment protocol. Depression was measured preoperatively with the self-reported Patient Health Questionnaire (PHQ-9). Patients with the probable diagnosis of a current episode of major depression showed significantly higher postoperative pain than patients without a depressive episode. On the other hand, patients with depression benefited from the implementation of standardized pain management. Our data suggest a predictive value of depression for severe postoperative pain. Patients with depression benefited from standardized postoperative pain therapy, but were still suffering from significantly higher postoperative pain.

[Development of a standardized back school for in-patient orthopaedic rehabilitation]. / Entwicklung eines standardisierten Rückenschulungsprogramms für die orthopädische Rehabilitation.

Medical rehabilitation in Germany is still lacking in patient education programmes that meet certain quality requirements such as the use of manuals, patient-oriented didactics, and evaluations of effectiveness. For patients with chronic low back pain, no standardized and evaluated back school programme has so far been available for routine use. In this paper, we demonstrate the development of a quality-assured back school based on a health-education programme of the German statutory pension insurance scheme. Both topics and didactics incorporate treatment evidence, practice guidelines, quality criteria for patient education and theories of health and illness behaviour. First, formative evaluation was conducted to assess patient acceptance and practicability of the manual. Second, effects of the back school programme were assessed on a short-term (at the end of rehabilitation), medium-term (6-month follow-up) and long-term (12-month follow-up) basis in a randomized controlled study of patients with low back pain (n=360). Results show a significant medium treatment effect in patients' knowledge about chronic back pain and its treatment at the end of rehabilitation (p<0.001; eta (2)=0.080). Furthermore, small to medium effects were also observed among some secondary outcomes, such as motivation to physical activity, pain beliefs and pain intensity. After the programme's medium- and long-term effects have been demonstrated, it will be recommended for implementation in medical rehabilitation. The manual meets the requirements that allow for a successful transfer into clinical practice.