[The S2k guideline: Indications for knee endoprosthesis : Evidence and consent-based indications for total knee arthroplasty]. / S2k-Leitlinie: Indikation Knieendoprothese : Evidenz- und konsensbasierte Indikationsstellung in der Knie-Endoprothetik (EKIT-Knie).

Total knee arthroplasty (TKA) is one of the most frequent surgical procedures in orthopaedic surgery. Until now there have not been any standardized indication criteria, which might contribute to the large geographical differences in the frequency of TKA. This guideline aims to consent minimal requirements (main criteria), additional important aspects (minor criteria), as well as relative and absolute contraindications for TKA. The following main criteria have been consented: knee pain, radiological confirmation of osteoarthritis or osteonecrosis, inadequate response to conservative treatment, adverse impact of knee disease on the patient's quality of life and the burden of suffering due to the knee disease. Relative contraindications have been consented as severe general disease with reduced life expectancy and a BMI ≥40; absolute contraindications are an active infection and if the patient is not able to undergo major surgery.

[What does pain intensity mean from the patient perspective? : A qualitative study on the patient perspective of pain intensity as an outcome parameter in treatment evaluation and on the interpretability of pain intensity measurements]. / Was bedeutet Schmerzintensität aus Sicht der Patienten? : Eine qualitative Studie zur Patientenperspektive auf Schmerzstärke als Konstrukt in der Therapieevaluation und die Interpretierbarkeit der Schmerzstärkemessung.

BACKGROUND: Pain intensity (PI) is a common outcome parameter in effectiveness studies on interdisciplinary multimodal pain therapy (IMPT), despite the fact that IMPT highlights dealing with rather than reducing chronic pain. Moreover, the measurement of pain intensity as a highly subjective experience is problematic. Patient participation is absolutely essential to examine the relevance of PI as a criterion of treatment success as well as to select/develop suitable measurement methods. METHOD: A qualitative multicenter study was conducted using focus groups with 69 patients (18-77 years; 80% female) at four different IMPT centers in Germany to discuss pain intensity as a therapy outcome parameter in IMPT, as well as the interpretability and feasibility of common measurement methods. RESULTS: The discussions emphasized that PI is a relevant, but not the primary, outcome in IMPT for patients. Patients' statements also demonstrate that there are some problems in measuring PI, for instance with regard to pain attacks. CONCLUSIONS: The focus group discussions suggested that, due to the highly subjective nature of PI, as well as (verbal) inaccuracies and a lack of standardization in common instruments, the measurement of pain intensity is a challenging task. These limitations should be taken into account in future studies.

[Patient perspectives in outcome research : Development of a focus group concept for collating patient perspectives on determination of effectiveness of multimodal pain therapy - A pilot study]. / Patientenperspektive in der Outcomeforschung : Entwicklung eines Fokusgruppenkonzepts zur Erhebung der Patientenperspektive auf die Effektivitätsbestimmung der multimodalen Schmerztherapie ­ eine Pilotstudie.

BACKGROUND: To assess the efficacy of multimodal pain therapy for chronic pain patients it is necessary to use suitable outcome domains as well as reliable and valid measurement instruments. Using pain intensity as an example, however, it is shown that there are critical issues with respect to suitability for chronic pain patients and the quality (e.g. content validity, feasibility and interpretability) of commonly used measurement instruments. METHOD: A focus group concept was designed to discuss the construct of pain intensity and common measurement instruments with chronic pain patients who underwent multimodal pain therapy. The focus group concept was tested in two pilot groups (N = 10) where eight issues previously established in guidelines were discussed. RESULTS: The results of the pilot studies affirmed that the construct of pain intensity as well as the measurement instruments must be critically considered when applied to chronic pain patients and the effectiveness of multimodal pain therapy. The concept of patient focus groups proved to be a suitable method for patient participation. Integrating patients should be considered not only in discussions of existing pain scales but also in developing new measurement instruments.

[Utilization of Physical Therapy Services in Germany from 2004 until 2014: Analysis of Statutory Health Insurance Data]. / Physiotherapeutische Versorgungssituation in Deutschland von 2004 bis 2014. Analyse des Verordnungsverhaltens bei Versicherten der Gesetzlichen Krankenversicherung.

Background: Both at the national and international levels, direct access for patients to physical therapy services is currently under debate. Direct access for patients seeking physical therapy care might reduce waiting time and costs, and thus be of benefit for patients and health insurance companies. To critically evaluate this situation, reliable and valid data are needed, but currently lacking. The aim of this study is to evaluate the health care situation for physical therapy services included in the catalogue of remedies from 2004 up to 2014 in Germany. Methods: To obtain information regarding physical therapy services included in the catalogue of remedies, the freely available "Heilmittel-Informations-System (GKV-HIS)" was used. Data from the regional Associations of Statutory Health Insurance Physicians as well as data from federal reports were extracted for the years from 2004 up to 2014. Results: Prescription of physical therapy increased continuously from 2004 and 2014. In 2004, 155 677 860 and in 2014, 254 695 514 physical therapies were prescribed (increase of 61%). The highest number of physical therapies was prescribed in Saxony for all years, whereas in North Rhine-Westphalia and Hessen the lowest number per 1 000 GKV insured persons. Gross sales from physical therapy services differed between federal states and were the highest in Saxony (2004: 59.8; 2009: 54.6, 2014: 76.7) and Baden-Wuerttemberg (2004: 60.0; 2009: 57.6; 2014: 68.0). Discussion: The results of this study show utilization of physical therapy services as defined in the catalogue of remedies in Germany to be heterogeneous. However, causal relationship cannot be identified on the basis of the analyzed data highlighting the need for further research. Criteria for structural-, process- and outcome-quality are needed to be able to evaluate the quality of physical therapy services. To ensure the quality of physical therapy services, interprofessional and patient relevant research is needed.

A systematic review of the outcomes reported in multimodal pain therapy for chronic pain.

BACKGROUND AND OBJECTIVE: There are no recommendations provided for the outcome domains of chronic pain that should be explicitly considered in each clinical trial to describe the efficacy and effectiveness of multimodal pain therapy (MPT). Our aims were to summarize all reported outcome domains in studies assessing the effects of MPT for chronic pain, and to subsequently inform a consensus-based development of a core outcome set of domains in this field. DATABASE AND DATA TREATMENT: Medline, Embase and AMED were searched for studies reporting on chronic pain for at least 3 months that applied MPT and investigated outcome domains. All reported outcome domains were extracted from eligible articles. The patient-reported outcome measurement information system (PROMIS) was applied for conceptual classification. RESULTS: From 3626 potentially relevant titles, 70 studies were included. The median and maximal numbers of outcome domains were 8 and 34, respectively. Although most studies (n = 45/70) assessed a combination of all three core health areas, i.e. physical, mental and social health, there was great variation in the specific domains chosen to address these core health areas. No outcome domain was measured consistently in all studies. After selection of all outcome domains which were reported in at least 10% of all studies included, we identified 14 different outcome domains, mostly operationalized through the domains pain intensity (n = 56/70) and depressive symptoms (n = 42/70). CONCLUSIONS: The current lack of standardization of outcome domains in MPT studies hinders to readily compare interventions from different trials and is a barrier towards evidence-based decision making. Based on these results, the development of a core outcome set of domains for MPT has been initiated.

[Personality and comorbidity: are there "difficult patients" in hip arthroplasty?]. / Persönlichkeitsprofil und Komorbidität: Gibt es den "schwierigen Patienten" in der primären Hüftendoprothetik?

BACKGROUND: Concomitant disorders at the time of surgery in addition to psychological and socioeconomic patient characteristics may influence treatment outcomes in hip arthroplasty. OBJECTIVES: To describe the impact of these factors on perioperative complications and postoperative results in terms of function, quality of life, and patient satisfaction. MATERIALS AND METHODS: Review of relevant clinical studies, meta-analyses, and presentation of our own results. RESULTS: Comorbidities in general, especially in combination, increase the perioperative risk profile. Socioeconomic factors (education, professional qualifications, social deprivation) in addition to psychological variables (depression, distressed personality) can have a major impact on postoperative functional outcomes and patient satisfaction. CONCLUSIONS: It is of crucial importance to avoid inequalities in the provision of joint replacement for patients with hip osteoarthritis and co-existing risk factors. Preventive strategies should be implemented to reduce the negative impact of comorbidities on treatment outcome. Personalized communication and education may be helpful in avoiding unrealistic patient expectations before hip replacement.

[Objectifying results in total knee arthroplasty: Is "patient satisfaction" adequate]. / Ergebnisobjektivierung bei Knietotalendoprothesen : Reicht die "Patientenzufriedenheit"?

BACKGROUND: Arthroplasty is an effective treatment for end-stage osteoarthritis of the knee and is one of Germany's most frequently performed orthopedic procedures. DISCUSSION: However, a considerable number of patient are not satisfied with the results after knee arthroplasty. The patient's perspective is particularly important for shared decision making. "Patient satisfaction" with the surgery is an expression of the patient's perspective, but might not be sufficient as the only outcome measure. There is no international consensus which outcome measures should be used after knee arthroplasty. CONCLUSION: Therefore, different measurement tools are used for the acquisition of a variety of outcome measures in order to quantify the results of knee arthroplasty. These tools should be used according to their reliability, validity, and responsiveness. This article provides an overview about available measurement tools.

[Scapulothoracic dysbalance in overhead athletes. Causes and therapy strategies]. / Skapulothorakale Dysbalancen bei Überkopfsportlern. Ursachen und Therapiestrategien.

BACKGROUND: A key element for movement of the arm is the position and motion of the scapula. A stable basis for efficient arm function is only possible if the scapula makes three dimensional movements coordinated with the upper arm. AIM: This article presents a discussion of causes, diagnosis and therapy options for scapular dyskinesis. MATERIAL AND METHODS: The article is based on a literature search in the PubMed database and taking own experience into account. RESULTS: Soft tissue and bony injuries, muscle insufficiency and dysbalance can alter the position and function of the scapula. This pathological position and motion is called scapular dyskinesis. This clinically presents as a prominent medial border and malrotation (lacking external rotation and posterior tilt) of the scapula when raising the arm. The clinical examination includes a visual inspection followed by clinical tests of the scapula at rest and during movement. Specific exercises of the musculature surrounding the scapula and specific techniques for schooling the senses for positioning and movement can harmonize the sequence of movements and restore the dynamic scapular stability. CONCLUSION: A conservative stepwise and stage-adapted exercise program can be used to treat scapular dyskinesis with good results.

Nonallergic comorbidities of atopic eczema: an overview of systematic reviews.

The aims of this overview are to synthesize the current evidence of published systematic reviews (SRs) on nonallergic comorbidities of atopic eczema (AE). EMBASE and MEDLINE were searched for SRs published from inception to November 2012. SRs were selected independently based on predefined inclusion criteria. Methodological quality of SRs included was assessed by two independent reviewers using the Revised Assessment of Multiple Systematic Reviews (R-AMSTAR) checklist. Nine SRs met all inclusion criteria. Six reviews addressing the association between AE and cancer suggest a decreased risk of glioma, meningioma, and acute lymphoblastic leukemia in patients with current or previous AE. One SR reported a consistent positive association of AE with attention-deficit hyperactivity disorder (ADHD). Diabetes mellitus type 1 and multiple sclerosis (MS) were not significantly related to AE in reviews based on cross-sectional and case-control studies. Patients with AE appear to be at decreased risk of brain tumors. The relationship of AE with Th1- and Th17-mediated (auto-)inflammatory conditions such as diabetes mellitus type 1 and MS should be clarified in prospective observational studies. Children with AE are at increased risk of ADHD. SRs on the risk of depression and Th17-mediated disorders such as inflammatory bowel disease of patients with AE are missing.

Barriers to the prescription of systemic therapies for moderate-to-severe psoriasis--a multinational cross-sectional study.

Despite the availability of a plethora of approved systemic treatments, high proportions of patients with moderate-to-severe psoriasis do not receive systemic treatment. This study aims at identifying barriers that hinder dermatologists from prescribing systemic treatments for psoriasis. A cross-sectional online survey in six countries (Canada, Germany, Spain, France, Italy, UK) was performed among 300 dermatologists, assessing the relevance of 15 potential barriers towards prescribing acitretin, cyclosporine, methotrexate, adalimumab, etanercept, infliximab and ustekinumab. Multivariate regression analyses were used to explore provider characteristics related to these barriers. Treatment barriers are perceived differently in the countries investigated, with Spanish, Italian and Canadian dermatologists being particularly concerned about the safety of methotrexate and Canadian dermatologists about the safety of cyclosporine. In general, safety concerns were the most important barrier to the use of cyclosporine, (18 % of participants' moderate/9 % strong or very strong barrier). Costs were being perceived as a strong or very strong barrier to the use of the different biologics by 19-24 % of the participants. Overall, country and work place were the most important determinants of treatment barriers. Sex, age, training, position and experience were minor determinants of treatment barriers. Medical reasons such as safety concerns or an inappropriate risk-benefit profile are particularly relevant barriers to the prescription of conventional treatments; whereas for biological treatments, economic reasons such as costs are more prevalent. Country specific analysis showed national differences in the perception of safety. The treatment barriers identified in this exploratory study should be confirmed in further health services research.