Appropriateness of exercise therapy delivery in chronic low back pain management: cross-sectional online survey of physiotherapy practice in Germany.

BACKGROUND: In Germany, exercise therapy represents the most commonly prescribed physiotherapy service for non-specific, chronic low back pain (NSCLBP). So far, little is known about current practice patterns of German physiotherapists in delivering this intervention. Thus, the aim of this study was to investigate the appropriateness of exercise therapy delivered to NSCLBP patients in German physiotherapy care and to identify practitioner-related drivers of appropriate exercise delivery. METHODS: We used a vignette-based, exploratory, cross-sectional, online-survey study design (76-items; data collection between May and July 2023). Eligible participants were required to hold a professional degree in physiotherapy and were required to be practicing in Germany. Access links to anonymous online surveys were spread via established German physiotherapy networks, educational platforms, social media, e-mail lists, and snowball sampling. Appropriateness of exercise therapy was calculated by an equally weighted total score (400 points) including scales on shared-decision-making, exercise dose selection, pain knowledge and self-management promotion. "Appropriate exercise delivery" was determined by a relative total score achievement of > 80%. "Partly appropriate exercise delivery" was determined by a relative total score achievement of 50-79%, and "inappropriate exercise delivery" by a score achievement of < 50%. Practitioner-related drivers of exercise appropriateness were calculated by bivariate and multiple linear regression analyses. RESULTS: 11.9% (N = 35) of 298 physiotherapists' exercise delivery was considered "appropriate", 83.3% (N = 245) was "partly appropriate", and 4.8% (N = 14) was "inappropriate". In the final multiple regression model, most robust parameters positively influencing appropriate delivery of exercise therapy were increased scientific literacy (B = 10.540; 95% CI [0.837; 20.243]), increased average clinical assessment time (B = 0.461; 95% CI [0.134; 0.789]), increased self-perceived treatment competence (B = 7.180; 95% CI [3.058; 11.302], and short work experience (B = - 0.520; 95% CI [-0.959; - 0.081]). CONCLUSION: Appropriate exercise delivery in NSCLBP management was achieved by only 11.9% of respondents. However, the vast majority of 95.2% of respondents was classified to deliver exercise therapy partly appropriate. Long work experience seemed to negatively affect appropriate exercise delivery. Positive influences were attributed to scientific literacy, the average clinical assessment time per patient as well as the perceived treatment competence in NSCLBP management. REGISTRATION: Open science framework: https://doi.org/10.17605/OSF.IO/S76MF .

[Determinants of use of rehabilitation services before entering disability pension: Time series analysis of insured members of the German Pension Insurance Federation in Berlin and Brandenburg]. / Determinanten zur Inanspruchnahme von Rehabilitationsleistungen vor Eintritt in die Erwerbsminderung: Zeitreihenanalyse von Versicherten der Deutschen Rentenversicherung Bund in Berlin und Brandenburg.

BACKGROUND: The age-standardized application rate for medical rehabilitation services of the German Pension Insurance Association has been declining since 2009. Two of the most frequent reasons for applying for rehabilitation services represent musculoskeletal disorders and mental disorders. The aim of this analysis was to identify factors influencing the utilization of rehabilitation services in the federal states of Berlin and Brandenburg. METHODS: The explorative time series analysis is based on a research dataset of the German Pension Insurance Federation. Insured persons of the German Pension Insurance Federation from the federal states of Berlin and Brandenburg with a diagnosis of musculoskeletal disorders or mental disorders were included. Descriptive differences in targeted and prognostic parameters were calculated using chi-square and t-test statistics. Predictive parameters for the utilization of medical rehabilitation services were calculated using binary, logistic regression analyses. RESULTS: A total of 11,257 insured cases were examined. For the population of insured persons from Berlin, the use of medical rehabilitation services showed significant prognostic variables for gender, age at retirement, marital status, level of education, occupational requirement level, total accumulated earning points, gross pension level, status of a temporary pension, health insurance status, and diagnosis group. For Brandenburg, significant prognostic variables were found for age at retirement, marital status, nationality, education level, occupational requirement level, total accumulated earning points, status of a temporary pension, occupational sector, and diagnosis group. CONCLUSION: In Berlin and Brandenburg mental disorders and sociodemographic parameters are associated with an increased probability of not claiming medical rehabilitation services before the onset of reduced earning capacity. It remains to be investigated which mechanisms cause people with mental disorders to make no use of medical rehabilitation services. Future analyses should examine isolated interaction mechanisms for the utilization of medical rehabilitation services, especially in the case of existing F-diagnoses. In addition, explanations for different influencing variables between states remain to be explored.

Research designs and instruments to detect physiotherapy overuse of low-value care services in low back pain management: a scoping review.

BACKGROUND: The provision of low-value physiotherapy services in low back pain management is a known but complex phenomenon. Thus, this scoping review aims to systematically map existing research designs and instruments of the field in order to discuss the current state of research methodologies and contextualize results to domains and perspectives of a referred low-value care typology. Ultimately, results will be illustrated and transferred to conditions of the German health care setting as care delivery conditions of physiotherapy in Germany face unique particularities. METHODS: The development of this review is guided by the analysis framework of Arksey and O'Malley. A two-stage, audited search strategy was performed in Medline (PubMed), Web of Science, and google scholar. All types of observational studies were included. Identified articles needed to address a pre-determined population, concept, and context framework and had to be published in English or German language. The publication date of included articles was not subject to any limitation. The applied framework to assess the phenomenon of low-value physiotherapy services incorporated three domains (care effectiveness; care efficiency; patient alignment of care) and perspectives (provider; patient; society) of care. RESULTS: Thirty-three articles met the inclusion criteria. Seventy-nine percent of articles focused on the appropriateness of physiotherapeutic treatments, followed by education and information (30%), the diagnostic process (15%), and goal-setting practice (12%). Study designs were predominantly cross-sectional (58%). Data sources were mainly survey instruments (67%) of which 50% were self-developed. Most studies addressed the effectiveness domain of care (73%) and the provider perspective (88%). The perspective of patient alignment was assessed by 6% of included articles. None of included articles assessed the society perspective. Four methodical approaches of included articles were rated to be transferrable to Germany. CONCLUSION: Identified research on low-value physiotherapy care in low back pain management was widely unidimensional. Most articles focused on the effectiveness domain of care and investigated the provider perspective. Most measures were indirectly and did not monitor low-value care trends over a set period of time. Research on low-value physiotherapy care in secondary care conditions, such as Germany, was scarce. REGISTRATION: This review has been registered on open science framework ( https://osf.io/vzq7k https://doi.org/10.17605/OSF.IO/PMF2G ).

Health literacy at work - individual and organizational health literacy, health supporting leadership and employee wellbeing.

BACKGROUND: Against the backdrop of demographic change and the shortage of skilled workers, employees' psychological wellbeing is of special interest for employers. In previous studies, individual health literacy has already been positively associated with psychological wellbeing. However, in order to improve health literacy, it is essential to take into account both the individual prerequisites and the demands and complexity of the system in which individuals operate. As current studies primarily focus on employees' individual health literacy and as the concept of organizational health literacy, so far, is mainly used in the context of health care institutions, this study investigates on the impact of organizational health literacy and health supporting leadership on the relationship between individual health literacy and employees' psychological wellbeing in a big German company based in the financial sector. METHODS: Data of an employee survey that was conducted in a big German company of the financial sector in October 2021 were analyzed by two mediation analyses using the PROCESS macro by Hayes for SPSS. A total of 2555 employees was included in analyses (51.4% male and 48.6% female). RESULTS: The relationship between individual health literacy and employees' psychological wellbeing is partially mediated by organizational health literacy, indirect effect ab 0.268 - CI [0.170, 0.378] and by health supporting leadership, indirect effect ab 0.228 - CI [0.137, 0.329]. CONCLUSION: Study results provide new indications for planning and evaluating the health strategy of companies. Regarding the psychological wellbeing of employees, practitioners and researchers should focus not only on individual health literacy but also on organizational health literacy and health supporting leadership.

Rural-urban differences in workplace health promotion among employees of small and medium-sized enterprises in Germany.

BACKGROUND: Rural and urban areas hold different health challenges and resources for resident small and medium-sized enterprises (SMEs) and their employees. Additionally, residents of urban and rural areas differ in individual characteristics. This study aims at investigating potential rural-urban differences (1) in the participation rate in workplace health promotion (WHP) and (2) in the relationship of WHP and health relevant outcomes in residents living in rural or urban German areas and working in SMEs. METHODS: Data of a large German Employee Survey in 2018 were used and analyzed by chi-square and t-tests and regression analyses regarding job satisfaction, sick days, and psychosomatic complaints. A total of 10,763 SME employees was included in analyses (23.9% living in rural, 76.1% living in urban areas). RESULTS: Analyses revealed higher participation rates for SME employees living in rural areas. SME employees living in urban areas reported more often the existence of WHP. Results showed (a) significance of existence of WHP for psychosomatic complaints and (b) significance of participation in WHP for job satisfaction in SME employees living in urban but not for those living in rural areas. CONCLUSION: The revealed disparities of (1) higher participation rates in SME employees living in rural areas and in (2) the relationship of WHP aspects with health relevant outcomes are of special interest for practitioners (, e.g. human resource managers), politicians, and researchers by providing new indications for planning and evaluating WHP measures.

Measuring social capital of hospital management boards in European hospitals: A validation study on psychometric properties of a questionnaire for Chief Executive Officers.

BACKGROUND: The commitment of hospital managers plays a key role in decisions regarding investments in quality improvement (QI) and the implementation of quality improvement systems (QIS). With regard to the concept of social capital, successful cooperation and coordination among hospital management board members is strongly influenced by commonly shared values and mutual trust. The purpose of this study is to investigate the reliability and validity of a survey scale designed to assess Social Capital within hospital management boards (SOCAPO-B) in European hospitals. METHODS: Data were collected as part of the EU funded mixed-method project "Deepening our understanding of quality improvement in Europe (DUQuE)" from 210 hospitals in 7 European countries (France, Poland, Czech Republic, Germany, Portugal, Spain, and Turkey). The Chief Executive Officers (CEOs) completed the SOCAPO-B scale (six-item survey, numeric scale, 1='strongly disagree' to 4='strongly agree') regarding their perceptions of social capital within the hospital management board. We investigated the factor structure of the social capital scale using exploratory and confirmatory factor analyses. Internal consistency was assessed using Cronbach's alpha, while construct validity was assessed through Pearson's correlation coefficients between the scale items. RESULTS: A total of 188 hospitals participated in the DUQuE-study. Of these, 177 CEOs completed the questionnaire(172 observations for social capital) Hospital CEOs perceive relatively high social capital among hospital management boards (average SOCAPO-B mean of 3.2, SD = 0.61). The exploratory factor analysis resulted in a 1-factor-model with Cronbach's alpha of 0.91. Pearson's correlation coefficients between the single scale items ranged from 0.48 to 0.68. CONCLUSIONS: The SOCAPO-B-scale can be used to obtain reliable and valid measurements of social capital in European hospital management boards, at least from the CEO's point of view. The brevity of the scale enables it to be a cost-effective and tool for measuring social capital in hospital management boards. TRIAL REGISTRATION: This validation study was not registered.

People with multimorbidity in outpatient care: patient-focused and needs-oriented healthcare management (MamBo) - protocol for a multiperspective evaluation study.

BACKGROUND: With demographic change, the number of noncommunicable diseases, chronic diseases and multimorbidity is increasing, and so is the demand for health services. This represents a further challenge for the healthcare system. An adequate and efficient treatment of multimorbid patients requires a well-structured, informed and cross-indicated treatment. Therefore, a new form of coordinated, managed and cross-sectoral care for multimorbid patients - the "MamBo" care model - has been developed. Along with the implementation of MamBo, a process and outcome evaluation will be carried out, which is described in this study protocol. The aim of the study is to evaluate the care model according to its implementation process and effectiveness. METHODS: The MamBo-care model will be evaluated in multi-perspective terms. Thus, a process and outcome evaluation with several data sources will be conducted: (1) Annual focus groups and individual interviews with those involved in the process. (2) Various primary data, including surveys of patients, physicians and practice staff at the time of enrolment and 1 year later to enable pre-post comparison. (3) Claim data from the health insurance of the MamBo population in comparison to a comparative population, formed by the propensity score matching method. (4) Process data of the care management. The analysis of qualitative data will be carried out by content analysis according to Mayring. For the analysis of the quantitative data, multivariate analyses are planned. DISCUSSION: A new form of coordinated care has been introduced to improve intersectoral care of multimorbid patients and reduce the workload on physicians. The effects of the MamBo care model are being investigated for patients, physicians and the cost units. The results will form the basis for the decision whether the care model should be transferred to standard care and what needs to be taken into account for implementation. TRIAL REGISTRATION: The study was retrospectively registered in the German Register for Clinical Studies (DRKS00014047) on June 28, 2019.

Emotional release and physical symptom improvement: a qualitative analysis of self-reported outcomes and mechanisms in patients treated with neural therapy.

BACKGROUND: Neural Therapy (NT) is a common complementary treatment approach using injections with short-acting local anesthetics to treat pain and chronic diseases. However, little is known about the underlying mechanisms and the domains of treatment response. This study therefore analyzed patient experiences following NT injections with procaine. METHODS: Maximum variation sampling was used to collect data from semi-structured interviews conducted with 22 hospital inpatients aged 59.6 ± 14.9 years (81.8% female). Each had multiple (9.4 ± 6.9) diagnoses. They were undergoing two weeks of integrative treatment, which included individualized NT. The interview data were analyzed in MAXQDA using qualitative content analysis. RESULTS: With injection, patients first described local anesthetic effects including temporary blocking of pain and increased local warmth. Second, patients reported on vegetative reactions frequently leading to turmoil within the body like initial aggravation of existing symptoms or the appearance of new, concealed or phantom symptoms. This often required the need for rest to deal with the treatment stimulus. As a third step, many patients could gain physical and emotional release and relief in symptoms, mood and functioning. Emotional release was often accompanied by weeping and initially overwhelmed affected patients with dissociated memories. However, in cases where patients were able to experience those memories with a new distance, a fourth step of integration was achievable. It included reframing processes as well as a gain in pain perception and body-awareness. As a possible fifth step, patients experienced improved mood, increased pain acceptance and empowerment. Adverse events of NT included pain from the injections, vegetative complaints and emotional turmoil that lasted for minutes or hours, with a maximum of two days. CONCLUSIONS: Patients treated with procaine injections reported different psychophysiological outcomes contributing to the understanding of the mechanisms underlying NT. Further efficacy studies should separate specific NT from non-specific/placebo effects. TRIAL REGISTRATION: DRKS00004567 .

Efficacy of the Alexander Technique in treating chronic non-specific neck pain: a randomized controlled trial.

OBJECTIVE: To test the efficacy of the Alexander Technique, local heat and guided imagery on pain and quality of life in patients with chronic non-specific neck pain. DESIGN: A randomized controlled trial with 3 parallel groups was conducted. SETTING: Outpatient clinic, Department of Internal and Integrative Medicine. SUBJECTS: A total of 72 patients (65 females, 40.7±7.9 years) with chronic non-specific neck pain. INTERVENTIONS: Patients received 5 sessions of the Alexander Technique--an educational method which aims to modify dysfunctional posture, movement and thinking patterns associated with musculoskeletal disorders. Control groups were treated with local heat application or guided imagery. All interventions were conducted once a week for 45 minutes each. MAIN MEASURES: The primary outcome measure at week 5 was neck pain intensity on a 100-mm visual analogue scale; secondary outcomes included neck disability, quality of life, satisfaction and safety. STATISTICS: Analyses of covariance were applied; testing ordered hypotheses. RESULTS: No group difference was found for pain intensity for the Alexander Technique compared to local heat (difference 4.5mm; 95% CI:-8.1;17.1; p=0.48), but exploratory analysis revealed the superiority of the Alexander Technique over guided imagery (difference -12.9 mm; 95% CI:-22.6;-3.1, p=0.01). Significant group differences in favor of the Alexander Technique were also found for physical quality of life (P<0.05). Adverse events mainly included slightly increased pain and muscle soreness. CONCLUSION: The Alexander Technique was not superior to local heat application in treating chronic non-specific neck pain. It cannot be recommended as routine intervention at this time. Further trials are warranted for conclusive judgment.

Low Inter-Rater Reliability and Reproducibility of Neck Reflex/"Adler-Langer" Points in Neural Therapy Diagnostics but Increased Pressure Pain Threshold after Therapy: Results of a Randomized Controlled Observer-Blind Trial.

BACKGROUND: Neck reflex points or Adler-Langer points are commonly used in neural therapy to detect so-called interference fields. Chronic irritations or inflammations in the sinuses, teeth, tonsils, or ears are supposed to induce tension and tenderness of the soft tissues and short muscles in the upper cervical spine. The individual treatment strategy is based on the results of diagnostic Adler-Langer point palpation. This study investigated the inter- and intra-rater reliability and explored treatment effects. METHODS: We performed a randomized controlled trial with 104 inpatients (80.8% female, 51.8 ± 12.74 years) of a German department for internal and integrative medicine. Patients were randomized to individual neural therapy according to the pathological findings (n = 48) or no treatment (n = 56). In each patient, three experienced raters (20-45 years of experience in neural therapy) and two novice raters (medical students) rated Adler-Langer points rigidity on a standardized rating scale ("strong," "weak," "none"). The patients independently evaluated the tenderness on palpation of the eight points using the same scale. Pressure pain thresholds were assessed at the eight Adler-Langer points. All patients were retested after 30 min. The five raters were blinded to treatment allocation and assessments of the other raters. Video recordings were obtained to assess the consistency of the areas tested by the different raters. RESULTS: Agreement between patients and raters (Cohen's kappa = 0.161-0.400) and inter-rater reliability were low (Fleiss kappa = 0.132-0.150). Moreover, the individual agreement (pre-post comparisons in untreated patients) was similarly low even in experienced raters (Cohen's kappa = 0.099-0.173). Video documentation suggests that raters do not place their fingers in the correct segments (percentage of correct position: 42.0-60.6%). Pressure pain thresholds at five of the eight Adler-Langer points showed significant changes after treatment compared to none in the control group. CONCLUSION: Under this artificial experimental setting, this method of Adler-Langer point palpation has not proven to be a reliable diagnostic tool. But it could be shown that, as claimed by the method, the tenderness in five of eight Adler-Langer points decreased after neural therapy.

SARS-CoV-2-Related Adaptation Mechanisms of Rehabilitation Clinics Affecting Patient-Centered Care: Qualitative Study of Online Patient Reports.

BACKGROUND: The SARS-CoV-2 pandemic impacted access to inpatient rehabilitation services. At the current state of research, it is unclear to what extent the adaptation of rehabilitation services to infection-protective standards affected patient-centered care in Germany. OBJECTIVE: The aim of this study was to determine the most relevant aspects of patient-centered care for patients in inpatient rehabilitation clinics under early phase pandemic conditions. METHODS: A deductive-inductive framework analysis of online patient reports posted on a leading German hospital rating website, Klinikbewertungen (Clinic Reviews), was performed. This website is a third-party, patient-centered commercial platform that operates independently of governmental entities. Following a theoretical sampling approach, online reports of rehabilitation stays in two federal states of Germany (Brandenburg and Saarland) uploaded between March 2020 and September 2021 were included. Independent of medical specialty groups, all reports were included. Keywords addressing framework domains were analyzed descriptively. RESULTS: In total, 649 online reports reflecting inpatient rehabilitation services of 31 clinics (Brandenburg, n=23; Saarland, n=8) were analyzed. Keywords addressing the care environment were most frequently reported (59.9%), followed by staff prerequisites (33.0%), patient-centered processes (4.5%), and expected outcomes (2.6%). Qualitative in-depth analysis revealed SARS-CoV-2-related reports to be associated with domains of patient-centered processes and staff prerequisites. Discontinuous communication of infection protection standards was perceived to threaten patient autonomy. This was amplified by a tangible gratification crisis of medical staff. Established and emotional supportive relationships to clinicians and peer groups offered the potential to mitigate the adverse effects of infection protection standards. CONCLUSIONS: Patients predominantly reported feedback associated with the care environment. SARS-CoV-2-related reports were strongly affected by increased staff workloads as well as patient-centered processes addressing discontinuous communication and organizationally demanding implementation of infection protection standards, which were perceived to threaten patient autonomy. Peer relationships formed during inpatient rehabilitation had the potential to mitigate these mechanisms.

The effects of modifying elements of written informed consent forms for elective surgical or invasive procedures: A systematic review.

OBJECTIVE: To study the effect of modifying content and design elements within written informed-consent-forms (ICF) for patients undergoing elective surgical or invasive procedures. METHODS: We included (quasi-)randomized trials in which a modified written ICF (e.g. visual aids) was compared to a standard written ICF. We searched PubMed, Web-of-Science and PsycINFO until 08/2021. Risk of Bias was assessed. The complexity of intervention was assessed using the Intervention Complexity Assessment Tool for Systematic Reviews. RESULTS: Eleven trials with 1091 participants were eligible. Effect sizes and levels of evidence varied from trivial to moderate andthere were contradictory findings for some outcomes. Providing patients with more informationin general or specific information on risks and complications mostly increased anxiety. The use of verbal risk presentation decreased anxiety and increased satisfaction.A lower readability level decreased anxiety and improved comprehension and knowledge. CONCLUSION: Our results suggest that providing more information and addressing certain types of risks have differential effects. While more information improved knowledge, it also increased anxiety. We did not find any or only insufficient evidence for many other possible ICF modifications. PRACTICE IMPLICATIONS: When developing ICFs the differential impact of different elements on patient important outcomes should be carefully considered.

Deficiency of C-C chemokine receptor 5 suppresses tumor development via inactivation of NF-κB and inhibition of monocyte chemoattractant protein-1 in urethane-induced lung tumor model.

To evaluate the significance of C-C chemokine receptor type 5 (CCR5) in lung tumor development, we compared carcinogen-induced tumor growth in CCR5 knockout (CCR5(-/-)) mice and wild-type (CCR5(+/+)) mice. CCR5(-/-) mice showed reduced urethane (1g/kg)-induced tumor incidence when compared with those of CCR5(+/+) mice. We investigated the activation of nuclear factor-kappaB/STAT3 since these are implicated transcription factors in the regulation of genes involving tumor growth. Significant inhibition of DNA-binding activity of nuclear factor-kappaB and STAT3, and the translocation of p50 and p65 into the nucleus and the phosphorylation of IĸB were found in the lungs of CCR5(-/-) mice compared with the lungs of CCR5(+/+) mice. Expression of apoptotic protein such as cleaved caspase-3, cleaved PARP and Bax was elevated, whereas the expression levels of survival protein such as Bcl-2 and cIAP1 was decreased in the lungs of CCR5(-/-) mice. Interestingly, we found that the level of monocyte chemoattractant protein-1 (MCP-1), a tumor growth-promoting cytokine, was significantly reduced in the lung tumor tissue and blood of CCR5(-/-) mice compared with the level in CCR5(+/+) mice. In addition, CCR5 small interfering RNA (siRNA) and inhibitor of MCP-1 blocked lung cancer cell growth, which was abolished by the addition of MCP-1 protein in cultured lung cancer cells. Moreover, inactivation of CD8(+) cytotoxic T cell and dendritic cells was significantly increased in the blood, lung tumors and spleens of CCR5(-/-) mice compared with that of CCR5(+/+) mice. Therefore, these results showed that CCR5 deficiency suppressed lung tumor development through the inhibition of nuclear factor-kappaB/STAT3 pathways and the downregulation of MCP-1 in the carcinogen-induced lung tumor model.

Integrative oncology for breast cancer patients: introduction of an expert-based model.

BACKGROUND: Malignant breast neoplasms are among the most frequent forms of cancer in the Western world. Conventional treatment of breast cancer may include surgery, hormonal therapy, chemotherapy, radiation and/or immunotherapy, all of which are often accompanied by severe side effects. Complementary and alternative medicine (CAM) treatments have been shown to be effective in alleviating those symptoms. Furthermore, with patient survival rates increasing, oncologists, psychologists and other therapists have to become more sensitive to the needs of cancer survivors that go beyond than the mere alleviation of symptoms. Many CAM methods are geared to treat the patient in a holistic manner and thus are also concerned with the patient's psychological and spiritual needs. DISCUSSION: The use of certain CAM methods may become problematic when, as frequently occurs, patients use them indiscriminately and without informing their oncologists. Herbal medicines and dietary supplements, especially, may interfere with primary cancer treatments or have other detrimental effects. Thus, expertise in this highly specialized field of integrative medicine should be available to patients so that they can be advised about the benefits and negative effects of such preparations and practices.Being a beneficial combination of conventional and CAM care, integrative oncology makes possible the holistic approach to cancer care. The concept of integrative oncology for breast cancer is jointly practiced by the Department of Internal and Integrative Medicine, Kliniken Essen-Mitte, academic teaching hospital of the University of Duisburg-Essen, and the Breast Center at Kliniken Essen-Mitte in Germany. This model is introduced here; its scope is reviewed, and its possible implications for the practice of integrative medicine are discussed. SUMMARY: Evidence-based integrative care is crucial to the field of oncology in establishing state-of-the-art care for breast cancer patients.

The effect of traditional cupping on pain and mechanical thresholds in patients with chronic nonspecific neck pain: a randomised controlled pilot study.

Introduction. Cupping has been used since antiquity in the treatment of pain conditions. In this pilot study, we investigated the effect of traditional cupping therapy on chronic nonspecific neck pain (CNP) and mechanical sensory thresholds. Methods. Fifty CNP patients were randomly assigned to treatment (TG, n = 25) or waiting list control group (WL, n = 25). TG received a single cupping treatment. Pain at rest (PR), pain related to movement (PM), quality of life (SF-36), Neck Disability Index (NDI), mechanical detection (MDT), vibration detection (MDT), and pressure pain thresholds (PPT) were measured before and three days after a single cupping treatment. Patients also kept a pain and medication diary (PaDi, MeDi) during the study. Results. Baseline characteristics were similar in the two groups. After cupping TG reported significantly less pain (PR: -17.9 mm VAS, 95%CI -29.2 to -6.6; PM: -19.7, 95%CI -32.2 to -7.2; PaDi: -1.5 points on NRS, 95%CI -2.5 to -0.4; all P < 0.05) and higher quality of life than WL (SF-36, Physical Functioning: 7.5, 95%CI 1.4 to 13.5; Bodily Pain: 14.9, 95%CI 4.4 to 25.4; Physical Component Score: 5.0, 95%CI 1.4 to 8.5; all P < 0.05). No significant effect was found for NDI, MDT, or VDT, but TG showed significantly higher PPT at pain-areas than WL (in lg(kPa); pain-maximum: 0.088, 95%CI 0.029 to 0.148, pain-adjacent: 0.118, 95%CI 0.038 to 0.199; both P < 0.01). Conclusion. A single application of traditional cupping might be an effective treatment for improving pain, quality of life, and hyperalgesia in CNP.

The benefit of a mechanical needle stimulation pad in patients with chronic neck and lower back pain: two randomized controlled pilot studies.

Objectives. The objective was to investigate whether a treatment with a needle stimulation pad (NSP) changes perceived pain and/or sensory thresholds in patients with chronic neck (NP) and lower back pain (BP). Methods. 40 patients with chronic NP and 42 patients with chronic BP were equally randomized to either treatment or waiting list control group. The treatment group self-administered a NSP over a period of 14 days. Pain ratings were recorded on numerical rating scales (NRSs). Mechanical detection thresholds (MDTs) and pressure pain thresholds (PPTs) were determined at the site of maximal pain and in the adjacent region, vibration detection thresholds (VDT) were measured at close spinal processes. The Northwick Park Neck Pain Questionnaire (NPQ) and the Oswestry Disability Index (ODI) were utilized for the NP and BP study, respectively. Results. NRS ratings were significantly reduced for the treatment groups compared to the control groups (NP: P = .021 and BP: P < .001), accompanied by a significant increase of PPT at pain maximum (NP: P = .032 and BP: P = .013). There was no effect on VDT and MDT. The NPQ showed also a significant improvement, but not the ODI. Conclusions. The mechanical NSP seems to be an effective treatment method for chronic NP and BP.

Research designs and instruments to detect physiotherapy overuse of low-value care services in low back pain management: a scoping review protocol.

BACKGROUND: The provision of low-value care services in low back pain management is a problem of global scope. Inappropriate imaging, overmedication, and overused invasive therapies are prevalent in physician services. Yet, little is known about overused low-value physiotherapy services. Most studies addressing physiotherapy overuse in low back pain management arose from countries in which physiotherapy is established in primary care. However, measures and instruments addressing physiotherapy overuse limitedly fit legislative conditions of health systems in which physiotherapy is a service of secondary care. Thus, this scoping review's purpose is to map existing research designs and instruments aiming to detect overused low-value physiotherapy services taking specific healthcare settings and aspects of medical overuse into account. METHODS: The development of this scoping review is guided by the Arksey and O'Malley framework. A two-step, peer-reviewed search strategy in accordance with the PRESS checklist will be conducted on MEDLINE (PubMed), Web of Science, and CINHAL. Additionally, gray literature will be searched on Google Scholar. Preprints of empirical studies will be included. Initially, two reviewers will independently screen articles for eligibility by title and abstract. A third reviewer will mediate discrepancies. Uncertainties will be eliminated by a full-text analysis or by contacting the corresponding authors. A four-step analytical process will guide result reporting focusing on major research questions outlined in this protocol. Numerical and narrative tables, graphics, and narrative summaries will be the methods to summarize and collate results. In the final step, the German health system will serve as an exemplary setting and frame to practically apply results. DISCUSSION: Results of this scoping review will help researchers to systematically select overuse measures referring to aspects of the overuse typology, specific healthcare settings, and physiotherapy services. It will further provide information on the limitations of present studies and will give advice on how to address them. Moreover, this review will illustrate to what degree existing studies succeed to comprehensively cover the concept of the overuse typology. SYSTEMATIC REVIEW REGISTRATION: This protocol has been registered on the open science framework ( https://doi.org/10.17605/OSF.IO/PMF2G ).

The Role of Psychological Wellbeing in a Cross-Provider Worksite Healthcare Management Program for Employees with Musculoskeletal Disorders.

Background: Musculoskeletal and mental disorders are often comorbid, with complex correlations of pain, impairment due to pain, disability, and psychological wellbeing. This study investigates the role of psychological wellbeing in a worksite healthcare program for employees within a German randomized controlled trial. Methods: For our analyses we used data of the module for minor musculoskeletal complaints (N = 180). The intervention included a workplace-related training and case manager support. Results: Changes over time were significant in the disability score (t(179) = 9.04, p < 0.001), pain intensity (t(179) = 9.92, p < 0.001), and psychological wellbeing (t(179) = −4.65, p < 0.001). Individuals with low vs. high psychological wellbeing showed significant differences in their disability scoret0,t1 (tt0(178) = −4.230, pt0 < 0.001, tt1(178) = −2.733, pt1 < 0.001), pain intensityt0,t1 (tt0(178) = −3.127, pt0 < 0.01, tt1(178) = −3.345, pt1 < 0.01, and motivationt0 (tt0(178) = 4.223, pt0 < 0.001). The disability score∆ mediates the impact of pain intensity∆ on psychological wellbeingt1 (beta = 0.155, p < 0.05). Psychological wellbeing∆ had an impact on the disability scoret1 (beta = −0.161, p < 0.01). Conclusions: The lower the psychological wellbeing is at an intervention's beginning, the higher the potential is for its improvement, which might affect individuals' experienced impairment due to pain. In order to achieve the best outcomes, interventions should include both pain-related and psychological aspects. Future research needs to explore the causality of the found interrelationships further.

"I'll leave that to the case managers." Healthcare Service Providers' Perceptions of Organizational Readiness for Change in a Randomized Controlled Trial-A Qualitative Analysis Exploring Implementation Success.

Up to 50% of unsuccessful implementations of organizational change are due to a lack of organizational readiness for change (ORC). This qualitative study aims to investigate the experiences of occupational physicians (OPs) and staff of test and training centers (ETTCs) with team effectiveness in the context of ORC. The change setting is the implementation of a new occupational health program in a multicentric randomized controlled trial for musculoskeletal disorders (MSD) in Germany. Two rounds of expert interviews with OPs (1st round: n = 10, 2nd round: n = 13) and one round of expert interviews with ETTCs (n = 9) were conducted and analyzed with a deductive-inductive procedure. The focus of the analysis was the assessment of change commitment and change efficacy, as well as their influence on general ORC on a collective level according to Weiner's model (2009). Differential critical assessment of change by the care providers led to a missing collective change commitment and consequently to a missing organizational change commitment. Main inhibiting factors include lacking feedback about (e.g., recruitment) success, limited time resources of and narrow communication between responsible study staff, along with a low rate of utilization and limited adherence of the study population. Main facilitators include standardized procedures and documentation along with easy-access digital tools. Researchers may use the findings to improve the development of new intervention studies, especially in a randomized setting.

Working Conditions of Occupational Physicians-A Scoping Review.

Occupational physicians (OPs) offer a wide range of health support for employees and are confronted with varying job characteristics and demands. They monitor occupational health and safety and promote work(place)-related health measures and assessments. While helping employees to (re)gain a healthy status, their own job satisfaction as well as the investigation of their working conditions have earned limited research attention. Thus, this scoping review aims to summarize the current state of knowledge concerning OPs' working conditions, i.e., work-related resources and stressors. PubMed, Web of Science and LIVIVO as well as grey literature were screened for relevant English or German articles until 10/2021. From a total of 1683 identified publications, we analyzed 24 full text articles that fulfilled all inclusion criteria. The overall study sample included 3486 male (54.6%), 2892 female (45.3%) and 5 diverse OPs, from which 1049 OPs worked in full-time (85.6%) and 177 in part-time (14.4%). The majority (72.4%) worked for the Occupational Health Service (OHS), 13% were self-employed, and 14.6% worked for a company/in-house service. The classification of stressors and resources was based on an inductively generated categorization scheme. We categorized 8 personal, relational and environmental resources and 10 stress factors. The main resources were support for personnel development and promotion, positive organizational policy, promoting work-life balance and other aspects of health. Key stressors were information deficits, organizational deficiency and uncertainty as well as socioeconomic influences and high professional obligations. The working conditions of OPs are still a topic with too little research attention. This scoping review reveals several starting points to maintain a healthy OP workforce and gives recommendations for action for the near future.