[Prevention of chronic pain in the German healthcare system : Current state and perspective]. / Vermeidung chronischer Schmerzen in der deutschen Gesundheitsversorgung : Derzeitiger Stand und Ausblick.

The current healthcare provision in Germany is established, in particular, for the diagnostics and treatment of chronic pain conditions; however, the current aim is to initiate the diagnostic and therapeutic approaches oriented towards the biopsychosocial pain model in the early stages of pain, i.e. before the onset of chronification, for patients with pain and a risk of chronification in order to actively avoid chronification processes. In this context, multiple risk factors play an important role for the diagnostic and therapeutic approaches as well as for the interdisciplinary multimodal pain therapy developed for this purpose. The Global Year of the International Association for the Study of Pain (IASP) 2020 addressed the prevention of (chronic) pain, a welcome opportunity to provide a short review of the evidence for and clinical experiences with timely diagnostic and therapeutic options and to summarize the current framework conditions and scientific recommendations for Germany. At the end of this article the implications for future research are summarized, particularly for the treatment of patients with pain and risk of chronification.

[Effectiveness of a risk-tailored short intervention to prevent chronic low back pain : A cluster-randomized study in general practice]. / Effekte einer risikoadaptierten Kurzintervention zur Prävention der Chronifizierung bei akuten Rückenschmerzen : Eine clusterrandomisierte Studie in Hausarztpraxen.

BACKGROUND: A subgroup of patients with acute low back pain (LBP) will develop chronic LBP. Risk factors summarized as yellow flags are fear-avoidance beliefs, depression, catastrophizing, and work-related problems. OBJECTIVE: The aim was to evaluate the effectiveness of screening for yellow flags in general practice followed by a risk-tailored group intervention compared to care as usual. METHODS: This is a cluster-randomized controlled trial in 35 general practices with 354 patients with acute LBP. Information or a standardized group intervention was offered to patients in the intervention group according to the screening algorithm with a short questionnaire for physical and psychosocial risk factors for chronic LBP. Standardized group information contained education concerning back pain and strategies for physical activities and planning of actions. Primary outcome was functional capacity assessed after 6 and 12 months with a questionnaire. Secondary outcomes were pain severity, fear avoidance beliefs, depression score, self-rated health and health service utilization. RESULTS: The intervention had no clinically relevant effect on the primary outcome functional capacity and secondary outcomes, although the course was consistently slightly better. Adherence to the offered intervention was low. Health service utilization was not altered to a relevant extent. A subgroup analysis comparing adherent and non-adherent patients showed a consistently better course of adherent patients. CONCLUSIONS: A risk-tailored short intervention to prevent chronic LBP in general practice had no significant impact on the clinical course compared to care as usual. A subgroup analysis comparing adherent and non-adherent patients suggests that it is possible to have a positive impact on patient-relevant outcomes.

Clinical relevance of persistent postoperative pain after total hip replacement - a prospective observational cohort study.

PURPOSE: The development of persistent postoperative pain may occur following surgery, including total hip replacement. Yet, the prevalence may depend on the definition of persistent pain. This observational cohort study explored whether the prevalence of persistent pain after total hip replacement differs depending on the definition of persistent pain and evaluated the impact of ongoing pain on the patient's quality of life 6 months after surgery. PATIENTS AND METHODS: Pre- and postoperative characteristics of 125 patients undergoing elective total hip replacement were assessed and 104 patients were available for the follow-up interview, 6 months after surgery. RESULTS: Six months after surgery, between 26% and 58% of patients still reported hip pain - depending on the definition of persistent pain. Patients with moderate-to-severe persistent pain intensity (>3 on a numerical rating scale) were more restricted in their daily life activities (Chronic Pain Grade - disability score) but did not differ in reported quality of life (Short-Form 12) from those with no pain or milder pain intensity. Maximal preoperative pain intensity and body mass index were the only independent factors influencing daily function 6 months after total hip replacement. CONCLUSION: These findings support a high prevalence of persistent postoperative pain after total hip replacement and a large variability depending on the definition used. There was a close relation between physical functioning and pain as well as relevance of the patient's psychological state at the time of the operation.

Pain experiences of patients with musculoskeletal pain + central sensitization: A comparative Group Delphi Study.

OBJECTIVES: Central sensitization (CS) is regarded as an important contributing factor for chronification of musculoskeletal pain (MSP). It is crucial to identify CS, as targeted multimodal treatment may be indicated. The primary objective of this study was therefore to explore pain experience of individuals with MSP+CS in order to gain a better understanding of symptoms in relation to CS from a patient perspective. The secondary objective was to investigate whether pain experiences of patients with MSP+CS differ from those of individuals with neuropathic pain (NP). METHODS: We conducted a comparative Group Delphi Study including patients with MSP+CS and neuropathic pain (NP). 13 guiding questions were used to gather information about sensory discriminatory, affective and associated bodily, mental and emotional phenomena related to the pain experience of patients. Descriptions were categorized using qualitative content analysis. Additionally, patients completed several pain related questionnaires. RESULTS: Nine participants with MSP+CS and nine participants with NP participated. The Delphi procedure revealed three main themes: psycho-emotional factors, bodily factors and environmental factors. Descriptions of patients with MSP+CS showed a complex picture, psycho-emotional factors seem to have a considerable impact on pain provocation, aggravation and relief. Impairments associated with mental ability and psyche affected many aspects of daily life. In contrast, descriptions of patients with NP revealed a rather mechanistic and bodily oriented pain experience. DISCUSSION: Patients with MSP+CS reported distinct features in relation to their pain that were not captured with current questionnaires. Insight in patient's pain experience may help to choose and develop appropriate diagnostic instruments.

Non-Specific Low Back Pain.

BACKGROUND: For many years, low back pain has been both the leading cause of days lost from work and the leading indication for medical rehabilitation. The goal of the German Disease Management Guideline (NDMG) on nonspecific low back pain is to improve the treatment of patients with this condition. METHODS: The current update of the NDMG on non-specific low back pain is based on articles retrieved by a systematic search of the literature for systematic reviews. Its recommendations for diagnosis and treatment were developed by a collaborative effort of 29 scientific medical societies and organizations and approved in a formal consensus process. RESULTS: If the history and physical examination do not arouse any suspicion of a dangerous underlying cause, no further diagnostic evaluation is indicated for the time being. Passive, reactive measures should be taken only in combination with activating measures, or not at all. When drugs are used for symptomatic treatment, patients should be treated with the most suitable drug in the lowest possible dose and for as short a time as possible. CONCLUSION: A physician should be in charge of the overall care process. The patient should be kept well informed over the entire course of his or her illness and should be encouraged to adopt a healthful lifestyle, including regular physical exercise.

Graded Activity for Older Adults with Chronic Low Back Pain: Program Development and Mixed Methods Feasibility Cohort Study.

BACKGROUND: Persistent pain is highly prevalent in older adults and can lead to functional limitations in activities of daily living, and to psychosocial distress. There is a lack of established active therapy programs, especially for older adults with chronic pain. OBJECTIVES: To develop a graded activity program and to evaluate its feasibility within a pilot study. DESIGN: Phase I/phase II trial of a complex intervention. A mixed methods design was chosen to evaluate the feasibility, acceptability, and preliminary evidence of effectiveness. SUBJECTS AND SETTING: Several experts participated in the program development. Sixteen community-dwelling older adults (73.9 ± 5.9 years on average) with chronic low back pain and three primary care physical therapists attempted the program. METHODS: Guided semi-structured interviews were conducted with all patients and therapists and used a content-analytic approach. Measurements of self-rated functional status (HFAQ), average pain (NRS), falls self-efficacy (FES-I), and catastrophizing and avoidance beliefs (CAS-D 65+) were applied at baseline and after the intervention. RESULTS: The interviews revealed high acceptance, satisfaction, and practicality. Besides improvements in function and pain, patients mentioned more positive attitudes towards pain, activity, and self-confidence. There was a clinically relevant increase in physical function by 20.3%, a decrease in pain intensity, and a reduction in catastrophizing and avoidance behavior. CONCLUSION: This graded activity program demonstrated feasibility and high acceptance in aged individuals and therapists. Future studies with larger samples must confirm effectiveness. The principles also appear applicable to other chronic pain conditions. The program could easily be implemented in routine primary care.

Pre-Existing Chronic Pain Influences the Severity of Acute Herpes Zoster Pain-A Prospective Observational Cohort Study.

OBJECTIVE: Pre-existing chronic pain has been associated with severe postoperative pain. To analyze the impact of chronic pain on non-surgical acute pain, a cohort of patients with acute herpes zoster was studied. METHODS: Consecutive patients, who needed hospitalization because of an acute zoster infection, were characterized and compared according to their pain history. Pain intensity, pain-related function, analgesic consumption, and psychological and physiological characteristics were assessed as baseline parameters on the day of hospitalization. Pain intensity and functional restrictions were evaluated on day 1, 4, 7, and on the day of discharge. The analgesic consumption was recorded and scored for each of these days. A multivariate analysis was performed for individual predictors. RESULTS: 59 patients were included; 25 patients (42.4%) had pre-existing chronic pain. These patients had more severe acute zoster pain on all assessment days and were more restricted in function, such as sleep quality and mobilization. There were, however, no differences in analgesic consumption. In patients without chronic pain, only the amount of analgesic consumption was associated with the severity of zoster pain. In contrast, in patients with chronic pain, the severity of the chronic pain, physical health, and the extent of neuropathic pain characteristics were associated with the intensity of zoster-related acute pain, while analgesic consumption was not. CONCLUSIONS: Patients with chronic pain had higher intensity of zoster-related acute pain. Furthermore, they showed more pain-related dysfunction and needed longer hospitalization than patients without chronic pain. These results go along with findings for acute postoperative pain.

The Influence of Chronic Pain on Postoperative Pain and Function After Hip Surgery: A Prospective Observational Cohort Study.

UNLABELLED: Pre-existing or chronic pain is an established risk factor for severe postoperative pain. In this prospective observational cohort study, we investigated whether a history of chronic pain, beyond the presence of hip-related pain, affected other postoperative factors including early mobilization, function, and psychological distress after hip surgery. Patients who underwent total hip replacement surgery were observed from the preoperative day until the seventh postoperative day. Before surgery, they were characterized by their pain history, pain intensity, function, and psychological characteristics. Postoperatively, pain intensity was evaluated on day 1, 3, 5, and 7 and the analgesic consumption was recorded for each of these days. Measures of function (functional questionnaire, ability to mobilize and to climb stairs, and range of hip motion) and psychological distress were re-evaluated on day 7. A history of chronic pain was associated with slower postoperative mobilization, poorer physical function, and greater psychological distress in addition to increased postoperative pain intensity. The comorbidity of a chronic pain disorder resulted in greater pain intensity after surgery, and also impeded postoperative rehabilitation. Identification of patients with a chronic pain disorder is necessary preoperatively so that appropriate pain management and rehabilitation can be planned to facilitate recovery. PERSPECTIVE: Chronic pain, beyond the presence of hip-related pain, is associated with slower postoperative mobilization, poorer physical function, and greater psychological distress after total hip replacement surgery. Identification of patients with chronic pain and establishment of multiprofessional perioperative management might improve postoperative rehabilitation of patients with chronic pain.

Measurement of Lumbar Spine Functional Movement in Low Back Pain.

OBJECTIVES: Individuals with low back pain (LBP) present with alterations or limitations of spinal mobility. The identification of simple clinical methods for evaluating functional movement of the spine is necessary to allow quantification of the degree of movement impairment and permit monitoring of patient improvement with rehabilitation. This study evaluated movement of the spine in 20 patients with chronic nonspecific LBP compared with 19 pain-free participants using a novel measurement device that permits the dynamic assessment of spinal movement in a rapid and subject-specific manner. METHODS: Two flexible sensor strips were fixed paravertebrally to the spine with each sensor strip measuring angles in 12 predetermined, adjacent, 25-mm-long segments. Maximum range of motion (ROM) and average angular velocity (AAV) of lumbar and pelvic movement were measured within identical angular and temporal frames during the descending and ascending phase of active lumbar flexion, extension, rotation, and lateral flexion following a standard choreography. Participants with LBP completed a number of questionnaires including the Tampa Scale of Kinesiophobia, Pain Catastrophizing Scale, and Spielberger State-Trait Anxiety Inventory. RESULTS: Across all movements, the individuals with LBP displayed 10% to 15% less ROM (P<0.05) and 15% to 30% less AAV (P<0.05) at both the pelvis and lumbar regions compared with controls. ROM as well as AAV, in most cases, were negatively correlated (R=-0.49 to -0.75) with the Tampa Scale of Kinesiophobia, Pain Catastrophizing Scale, and Spielberger State-Trait Anxiety Inventory in the LBP group (all P<0.05) especially during the initial descending phase of movement. DISCUSSION: This study provide support for the utility of this device for quantifying movement impairments in individuals with fairly low levels of LBP and general functional limitations. The results show that velocity measurements rather than ROM show the greatest differences in individuals with LBP compared with asymptomatic participants. Impaired lumbar and pelvis movement was correlated to the individuals with LBP's degree of anxiety, fear, and catastrophizing.

Significance of physical performance tests for patients with low back pain.

OBJECTIVES: Several research groups established functional tests to obtain performance data for mobility-related activities in patients with low back pain (LBP). In our study we aimed to assess the construct validity and associations with other measures of a battery of functional tests in relationship to physical performance on the one hand and physical capacity and variables of pain, disability and psychological variables on the other. DESIGN: Eight physical performance tests of everyday activities such as climbing stairs, picking up an object from the floor, bending forward, and sitting up from supine position etc. were evaluated in 106 patients with LBP and 106 control subjects. RESULTS: Distribution of results in each test demonstrated a marked overlap in a number of tests between those with and those without back pain. In a factor analysis we found pronounced differences in the factorial structure of the data between patients and control subjects as well in the bivariate correlations between functional test results. There was a strong relationship between self-report disability rating (FFbH-R) and physical performance tests especially in patients whereas physical capacity tests had less relationship in patients and not at all in the control subjects. CONCLUSION: In contrast to the past and present literature, our results suggest that physical performance tests have an inherent problem to sharply differentiate patients with back pain from healthy controls and problems with inter-rater reliability. Physical performance seems to be more a matter of patients' perception of generalized disability than of restricted function.

Low back pain patient subgroups in primary care: pain characteristics, psychosocial determinants, and health care utilization.

OBJECTIVES: In industrialized countries, low back pain (LBP) is one of the leading causes for prolonged sick leave, early retirement, and high health care costs. Providing the same treatments to all patients is neither effective nor feasible, and may impede patients' recovery. Recent studies have outlined the need for subgroup-specific treatment allocation. METHODS: This is a cross-sectional study that used baseline data from consecutively recruited patients participating in a guideline implementation trial regarding LBP in primary care. Classification variables were employment status, age, pain intensity, functional capacity (HFAQ), depression (CES-D), belief that activity causes pain (FABQ subscale), 2 scales of the SF-36 (general health, vitality), and days in pain per year. We performed k-means cluster analyses and split-half cross-validation. Subsequently, we investigated whether the resulting groups incurred different direct and indirect costs during a 6-month period before the index consultation. RESULTS: A 4-cluster solution showed good statistical quality criteria, even after split-half cross-validation. "Elderly patients adapted to pain" (cluster 1) and "younger patients with acute pain" (cluster 4) accounted for 55% of all patients. Cluster validation showed the lowest direct and indirect costs in these groups. About 72% of total costs per patient referred to clusters 2 and 3 ("patients with chronic severe pain with comorbid depression" and "younger patients with subacute pain and emotional distress"). DISCUSSION: Our study adds substantially to the knowledge of LBP-related case-mix in primary care. Information on differential health care needs may be inferred from our study, enabling decision makers to allocate resources more appropriately and to reduce costs.

Implementation of a guideline for low back pain management in primary care: a cost-effectiveness analysis.

STUDY DESIGN: Cost-effectiveness analysis alongside a cluster randomized controlled trial. OBJECTIVE: To study the cost-effectiveness of 2 low back pain guideline implementation (GI) strategies. SUMMARY OF BACKGROUND DATA: Several evidence-based guidelines on management of low back pain have been published. However, there is still no consensus on the effective implementation strategy. Especially studies on the economic impact of different implementation strategies are lacking. METHODS: This analysis was performed alongside a cluster randomized controlled trial on the effectiveness of 2 GI strategies (physician education alone [GI] or physician education in combination with motivational counseling [MC] by practice nurses)--both compared with the postal dissemination of the guideline (control group, C). Sociodemographic data, pain characteristics, and cost data were collected by interview at baseline and after 6 and 12 months. low back pain-related health care costs were valued for 2004 from the societal perspective. RESULTS: For the cost analysis, 1322 patients from 126 general practices were included. Both interventions showed lower direct and indirect costs as well as better patient outcomes during follow-up compared with controls. In addition, both intervention arms showed superiority of cost-effectiveness to C. The effects attenuated when adjusting for differences of health care utilization prior to patient recruitment and for clustering of data. CONCLUSION: Trends in cost-effectiveness are visible but need to be confirmed in future studies. Researchers performing cost-evaluation studies should test for baseline imbalances of health care utilization data instead of judging on the randomization success by reviewing non-cost parameters like clinical data alone.

Does attrition bias longitudinal population-based studies on back pain?

BACKGROUND AND AIMS: Longitudinal population studies are a keystone in describing the course of back pain over time. Yet, potential bias because of repeated attrition has received little attention. This study aims to identify those back pain related indicators most susceptible to bias and to discuss practical consequences for back pain research. METHODS: Analyses were based on a population-based longitudinal multi-centre postal back pain survey with two postal follow-up measurements within 2 years. The baseline sample comprised 9263 subjects. Different sets of measures at entry were used to predict subsequent attrition: Socio-demographic variables, indicators of back pain, health related measures, and response behaviour. Back pain related indicators comprised prevalence estimates, pain intensity, disability, and radiating pain. Weighted and unweighted back pain outcomes were compared at the first and second follow-up to assess bias. RESULTS: Only 52.3% of the eligible participants at baseline continued participation till the second follow-up. Age and prior response behaviour were the best predictors of attrition while health and back pain related variables were of less importance. Differences between weighted and unweighted estimates of back pain related indicators were small to negligible, thus indicating little bias in point estimates. Unexpectedly, the reported back pain burden slightly declined over time. CONCLUSION: The representativeness of the sample is consecutively reduced because of differential attrition over the different measurement points. Despite this, bias due to attrition has a marginal impact on the point estimates of virtually all back pain related outcomes.

Assessing a risk tailored intervention to prevent disabling low back pain--protocol of a cluster randomized controlled trial.

BACKGROUND: Although most patients with low back pain (LBP) recover within a few weeks a significant proportion has recurrent episodes or will develop chronic low back pain. Several mainly psychosocial risk factors for developing chronic LBP have been identified. However, effects of preventive interventions aiming at behavioural risk factors and unfavourable cognitions have yielded inconsistent results. Risk tailored interventions may provide a cost efficient and effective means to take systematic account of the individual risk factors but evidence is lacking. METHODS/DESIGN: This study will be a cluster-randomised controlled trial comparing screening and a subsequent risk tailored intervention for patients with low back pain to prevent chronic low back pain compared to treatment as usual in primary care. A total of 600 patients from 20 practices in each study arm will be recruited in Berlin and Goettingen. The intervention comprises the following elements: Patients will be assigned to one of four risk groups based on a screening questionnaire. Subsequently they receive an educational intervention including information and counselling tailored to the risk group. A telephone/email consulting service for back pain related problems are offered independent of risk group assignment. The primary outcomes will be functional capacity and sick leave. DISCUSSION: This trial will evaluate the effectiveness of screening for risk factors for chronic low back pain followed by a risk tailored intervention to prevent chronic low back pain. This trial will contribute new evidence regarding the flexible use of individual physical and psychosocial risk factors in general practice. TRIAL REGISTRATION: ISRCTN 68205910.

Low back pain in primary care: costs of care and prediction of future health care utilization.

STUDY DESIGN: Cost of illness study alongside a randomized controlled trial. OBJECTIVE: To describe the costs of care for patients with low back pain (1) and to identify patient characteristics as predictors for high health care cost during a 1-year follow-up (2). SUMMARY OF BACKGROUND DATA: Low back pain (LBP) is one of the leading causes of high health care costs in industrialized countries (Life time prevalence, 70%). A lot of research has been done to improve primary health care and patients' prognosis. However, the cost of health care does not necessarily follow changes in patient outcomes. METHODS: General practitioners (n = 126) recruited 1378 patients consulting for LBP. Sociodemographic data, pain characteristics, and LBP-related cost data were collected by interview at baseline and after 6 and 12 months. Costs were evaluated from the societal perspective. Predictors of high cost during the subsequent year were studied using logistic regression analysis. RESULTS: Mean direct and indirect costs for LBP care are about twice as high for patients with chronic LBP compared to acutely ill patients. Indirect costs account for more than 52% to 54% of total costs. About 25% of direct costs refer to therapeutic procedures and hospital or rehabilitational care. Patients with high disability and limitations in daily living show a 2- to 5-fold change for subsequent high health care costs. Depression seems to be highly relevant for direct health care utilization. CONCLUSION: Interventions designed to reduce high health care costs for LBP should focus on patients with severe LBP and depressive comorbidity. Our results add to the economic understanding of LBP care and may give guidance for future actions on health care improvement and cost reduction.

Are fear-avoidance beliefs in low back pain patients a risk factor for low physical activity or vice versa? A cross-lagged panel analysis.

OBJECTIVE: The assumption that low back pain (LBP) patients suffer from "disuse" as a consequence of high fear-avoidance beliefs is currently under debate. A secondary analysis served to investigate whether fear-avoidance beliefs are associated cross-sectionally and longitudinally with the physical activity level (PAL) in LBP patients. METHODS: A total of 787 individuals (57% acute and 43% chronic LBP) were followed up over a period of one year with measurements of fear-avoidance beliefs and physical activity level. Fear-avoidance beliefs concerning physical activity were measured by the physical-activity subscale of the FABQ (Fear-Avoidance Beliefs Questionnaire), the physical activity level was assessed in weighted metabolic equivalents (MET) hours/week with a German self-report questionnaire. Data were investigated by structural equation modelling in a cross-lagged panel design for the whole sample and separately for acute and chronic LBP. RESULTS: The acute and chronic sub sample increased their total physical activity level significantly after one year. The structural equation modelling results did not support the disuse-aspect inherent in the fear-avoidance belief model. Cross-lagged path coefficients were low (.04 and .05 respectively) and, therefore, did not allow to predict final physical activity by initial fear-avoidance beliefs or vice versa. DISCUSSION: Consequently, due to missing links between fear-avoidance beliefs and physical activity in a longitudinal design, the assumptions of the fear-avoidance belief model have to be questioned. These findings are in line with other investigations published recently. Most probably, "fear-avoidance belief" represents a cognitive scheme that does not limit activity per se, but only is directed to the avoidance of specific movements.

[Chronic low back pain--need for an interdisciplinary approach]. / Chronischer Rückenschmerz--Interdisziplinäre Diagnostik und Therapie.

Low back pain is a burden in health policy and medical care. One of the main problems in that field comes from the fact that a minor part of all patients developchronic pain; those claiming for the main part of all costs. The transition from acute to chronic pain is dominated by psychological factors and there is a strong need to identify them at a very early stage of the illness. Concerning diagnostic procedures it is at first necessary to eliminate red flags. Afterwards, treatment is dominated by motivating the patients to intensify their daily activities and to inform them about the harmless nature of non-specific back pain. In case of chronic pain syndromes there is a strong need for interdisciplinary procedures in diagnosis and multiprofessional treatment. Multimodal treatment should be modelled on the concept of functional restoration.