[Avoidance-endurance fast screening (AE-FS) : Content and predictive validity of a 9­item screening instrument for patients with unspecific subacute low back pain]. / Avoidance-Endurance Fast-Screen (AE-FS) : Inhalts- und Vorhersagevalidität eines 9­Item-Screeninginstruments für Patienten mit unspezifischen subakuten Rückenschmerzen.

BACKGROUND: Among screening measures to assess psychosocial risk factors (yellow flags) for chronic low back pain (LBP) economic tools which address dysfunctional endurance pain responses besides emotional distress and fear-avoidance pain processing are rare. Targeting contrasting types of pain processing might improve stratified patient counselling. OBJECTIVE: The aim of the study was to develop a short screening method, based on the avoidance-endurance model of pain and to investigate the prognostic validity for pain intensity, disability and physical function. MATERIAL AND METHODS: A prospective observational study was carried out on 144 patients with subacute LBP (<3 months) from 7 general practitioners and 5 orthopedic practices. The 9­item avoidance-endurance fast screening (AE-FS) was derived from a previous 37-item screening using correlational and receiver operating curve (ROC) analyses and the agreement of subgrouping was calculated using Cohen's kappa. Primary outcomes were assessed after 6 months by mail in 124 patients (86%). Endpoints were pain intensity and disability. RESULTS: The classification of subgroups as high and low risk by both measures had considerable agreement with a value of 0.71 (Cohen's Kappa). The sensitivity to predict pain intensity >2 was high (82%) as was the positive predictive value (80%) but the negative predictive value was moderate (61%). The ROC (AUC) characteristics (95% confidence interval CI) were 0.70 (0.60-0.80) for pain intensity and for limitations in the pain disability index (PDI) 0.70 (0.55-0.87). DISCUSSION: The 9­item AE-FS displayed sufficient prognostic validity for all three outcomes in a sample of primary care patients with subacute LBP. The differentiation of the high-risk patients into fear-avoidance and endurance-related pain processing enables the physician to provide an individualized counselling with the aim of a healthy balance between stress and relaxation.

[Psychosocial risk factors for chronic back pain in the general population and in competitive sports : From theory to clinical screening-a review from the MiSpEx network]. / Psychosoziale Risikofaktoren für chronischen Rückenschmerz in der Allgemeingesellschaft und im Leistungssport : Von der Modellbildung zum klinischen Screening ­ ein Review aus dem MiSpEx-Netzwerk.

BACKGROUND: Lumbar back pain and the high risk of chronic complaints is not only an important health concern in the general population but also in high performance athletes. In contrast to non-athletes, there is a lack of research into psychosocial risk factors in athletes. Moreover, the development of psychosocial screening questionnaires that would be qualified to detect athletes with a high risk of chronicity is in the early stages. The purpose of this review is to give an overview of research into psychosocial risk factors in both populations and to evaluate the performance of screening instruments in non-athletes. METHODS: The databases MEDLINE, PubMed, and PsycINFO were searched from March to June 2016 using the keywords "psychosocial screening", "low back pain", "sciatica" and "prognosis", "athletes". We included prospective studies conducted in patients with low back pain with and without radiation to the legs, aged ≥18 years and a follow-up of at least 3 months. RESULTS: We identified 16 eligible studies, all of them conducted in samples of non-athletes. Among the most frequently published screening questionnaires, the Örebro Musculoskeletal Pain Screening Questionnaire (ÖMPSQ) demonstrated a sufficient early prediction of return to work and the STarT Back Screening Tool (SBT) revealed acceptable performance predicting pain-related impairment. The prediction of future pain was sufficient with the Risk Analysis of Back Pain Chronification (RISC-BP) and the Heidelberg Short Questionnaire (HKF). CONCLUSION: Psychosocial risk factors of chronic back pain, such as chronic stress, depressive mood, and maladaptive pain processing are becoming increasingly more recognized in competitive sports. Screening instruments that have been shown to be predictive in the general population are currently being tested for suitability in the German MiSpEx research consortium.

[Pilot study on pain response patterns in chronic low back pain. The influence of pain response patterns on quality of life, pain intensity and disability]. / Schmerzverarbeitungspattern bei chronischen Rückenschmerzen Pilotstudie. Der Einfluss von "Avoidance-Endurance"-Modell-Pattern auf die Lebensqualität, Schmerzintensität und Beeinträchtigung.

BACKGROUND: The variables pain intensity (SI), disability (DS) and quality of life (QoL) belong to a set of primary patient-based outcomes in chronic low back pain (CLBP). The avoidance-endurance model (AEM) assumes three maladaptive and one adaptive pain response pattern. The purpose of this study was to study the level and course of the outcomes with regard to the four AEM patterns. PATIENTS AND METHODS: A total of 52 CLBP inpatients were investigated at 2 points in time: during the first days after admission and 6 months after the acute exacerbation of pain. Differences between AEM patterns were analyzed with repeated measurement analyses of variance. RESULTS: Groups differences were found for SI (F((3, 48))=2.82, p<0.05), general (F((3, 48))=6.78, p<0.05) and health-related QoL (F((3, 48))=5.99, p <0.05). In contrast, for the variable disability only a significant time effect was found. CONCLUSION: The results show differences in the level and process of SI, DS and QoL between the subgroups. An AEM-based classification of subgroups is also reasonable for CLPB patients.

Quality of life of patients with renal cell carcinoma or prostate cancer after radical surgery.

OBJECTIVES: To study the impact of radical tumour surgery in prostate and renal cell cancer patients on quality of life (QOL). METHODS: In 38 male patients suffering from organ-confined prostate or renal cell cancer, a prospective study was performed. For the evaluation of QOL, we used the EMPK (Erfassung multipler psychischer Konstrukte). Urologic symptoms were evaluated with a specially designed symptom score. The test instrument was filled out the day before surgery and one year after operation. RESULTS: The EMPK was able to detect and describe significant changes in certain aspects of QOL in renal cell cancer and prostate cancer patients. Moreover, there seems to be a difference between the two groups. A direct relation between QOL and the different quality and quantity of operation-related symptoms, however, could not be proven. CONCLUSIONS: In this pilot study, radical surgical therapy did not significantly change QOL in prostate cancer patients, but seemed to have a positive influence on the QOL of renal cell cancer patients.

[Psychological mechanisms in the transition from acute to chronic pain: over- or underrated?]. / Psychologische Mechanismen in Prozess der Schmerzchronifizierung - Unter- oder überbewertet?

INTRODUCTION: During the last 20 years a great number of studies have emphasized the potential role of psychological factors as relevant predictors for the first onset of back pain as well as for the development of chronic pain. The formulation of a biopsychosocial perspective of the etiology and chronicity of back pain was a natural consequence. Actual questions concern the relative impact of psychological risk factors in the process of chronicity of back pain compared to biomedical, social and occupational factors. METHODS: Whereas several review articles regarding the role of psychological risk factors are available up to now, a recently published review conducted by Steven Linton was the first systematic analysis of well controlled prospective studies published since 1967. Using a grading system similar to that recommended for guidelines the author defined a level A evidence when at least two good-quality prospective studies supported the prospective power of a variable. Level B evidence had support from one prospective study. Level C represented inconclusive data and level D indicated that no studies met the criteria. Based on a literature search of more than 900 studies, 37 good-quality prospective studies were analysed in detail. RESULTS: The results indicated level A evidence for the following interrelations: (1) Psychosocial variables, especially chronic distress in daily life, depression and work dissatisfaction were clearly associated with the onset of back and neck pain (2). Psychological variables, especially chronic stress in daily life, work dissatisfaction, depression and pain-related cognitions and coping behaviour were clearly linked to the transition from acute to chronic pain and disability (3). Psychological variables generally had more prospective power than biomedical, social or objective occupational variables. Among the pain-related cognitions, catastrophizing and fear-avoidance-beliefs yielded the most empirical support. Among coping behaviour passive coping stretegies such as avoiding behaviour was most important. At least level B evidence has been shown for the counterpart of an extreme suppressive coping behaviour. Patients who tended to suppress or ignore pain in order to finish all activities they started, who were unable to integrate phases of passive relaxation into the daily routine displayed a high risk of chronicity of pain 6 months after an acute phase of pain. One international and two German good-quality prospective studies have shown the predictive power of a maladaptive suppressive behaviour pattern. Based on the avoidance-endurance-model of pain chronification, both extreme and one-sided passive pain coping as well as one-sided suppressive coping modes were conceptualized as maladaptive due to the process of chronicity. We assume that extreme passive behaviour will lead to immobility and muscular atrophy. Neurophysiological processes of sensitization will further lead to the development of chronic pain. On the other hand, extreme suppressive behaviour will lead to an overuse of muscles and joints with a repetitive combination of muscular hyperactivity and pain. These repetitive pain experiences will also elicit neurophysiological processes of sensitization. (4) Psychosocial variables displayed more predictive power than biomedical or biomechanical factors. (5) Psychosocial factors may be used as predictors of the risk for developing long-term pain and disability. Mixed empirical evidence has been shown for the role of personality factors (level C evidence) and no support has been found for the idea of a "pain prone" personality disorder or for the role of sexual and physical abuse. DISCUSSION: 20 years of research, several qualitative reviews and a recently published systematic review of 37 good-quality prospective studies regarding the role of psychological, biomedical, social and objective occupational factors in the process of chronicity of back pain revealed that psychological factors are significantly related to the onset of back pain as well as to the development of chronic pain. Furthermore, the psychological factors displayed more predictive power than biomedical or biomechanical variables. As a consequence for clinical practice, these psychological risk factors have to be considered as "yellow flags" if a back pain problem won't respond to medical treatment for more than four weeks. As a further consequence, special risk factor - based psychosocial interventions should be offered in addition to the medical treatment to patients with high psychological risk factors for the development of chronic pain. The efficacy of such an interdisciplinary care in the very early phases of back pain in order to prevent chronicity of pain and disability has been published recently by our group.