[A German Survey of Goal Setting and Goal Agreement in Medical Rehabilitation]. / Reha-Zielvereinbarungen in der medizinischen Rehabilitation: eine bundesweite Bestandsaufnahme.

AIM: To describe the current practice of goal setting and goal agreement in the Medical rehabilitation in Germany. METHODOLOGY: Rehabilitation centers contracted by the German Pension Insurance and covering all indications were approached by a questionnaire survey. RESULTS: The percentage of questionnaires returned was 48.1% (N=716). 93.3% of the responders replied that the importance placed on "rehab goals" at their institution was "very high" (41.1%) or "quite high" (52.2%). Our findings, however, reveal the potential for improving the quality of setting rehab goals in the fields of "process orientation", "team orientation" and "patient orientation". CONCLUSION: Rehabilitation centers perceive current practice in goal setting and goal agreement as being on a high level. The rehabilitation centers name many positive aspects as well as barriers to goal setting. Those problems should be more frequently addressed in practice.

[Collaborative Goal Setting in Rehabilitation (ParZivar II): Evaluation of an Intervention in Patients with Chronic Back Pain]. / Partizipative Zielvereinbarung in der Rehabilitation (ParZivar II): Evaluation einer Intervention bei Patienten mit chronischen Rückenschmerzen.

OBJECTIVE: The "ParZivar II" project had 2 aims: optimization of the "ParZivar I" intervention by individual coaching of physicians, and evaluation of the optimized intervention. METHODS: The intervention was evaluated in a sequential control group design in 4 rehabilitation facilities with 3 measurement points. A total of n=279 patients with chronic low back pain participated in the study. RESULTS: The optimized intervention shows the potential to statistically significantly improve proximal outcomes (e. g. goal-centric processes or patient-physician interaction). Regarding distal outcomes, no statistically significant differences were found. CONCLUSION: The "ParZivar" intervention is a suitable approach to increase participative goal setting. Due to the complexity of the intervention, problems of dissemination and the potential for improvement in study design, there is a need for further research.

[Evaluation of a collaborative goal setting intervention in patients with chronic back pain]. / Evaluation einer Intervention zur partizipativen Vereinbarung von Rehabilitationszielen bei Patienten mit chronischen Rückenschmerzen.

BACKGROUND AND OBJECTIVE: Although setting rehabilitation goals is considered to be a core rehabilitation process, in actual rehabilitation practice there is a considerable need for improvement with respect to consistent goal orientation. The objective of the PARZIVAR project was therefore to develop an intervention for participative goal setting in medical rehabilitation. This article reports the results of the evaluation of the PARZIVAR intervention in patients with chronic back pain. METHODS: The PARZIVAR intervention was evaluated in a sequential control group design with 3 measurement points (before the start of rehabilitation, at the end of rehabilitation, and at 6-month follow-up). The proximal endpoints were defined as patient perception of participative goal setting, subjective awareness of goals, and satisfaction with goal setting. The distal endpoints were intensity of pain and generic and illness-specific functioning. RESULTS: Overall, the degree of achieving aspects of participative goal setting was higher in the intervention group. There were no differences regarding satisfaction with goal setting, however, and distal outcomes also remained unchanged after the intervention was implemented. DISCUSSION: Participation in the PARZIVAR intervention was partially reflected in the perception of the rehabilitation patients, but the effects regarding distal outcomes in the intervention group did not exceed those of usual care. There is a need for more research into how concepts of goal setting can be improved in the future to better address the diverse functions of goal setting.

[DGRW-Update: musculo-skeletal diseases]. / DGRW-Update: Erkrankungen des Muskel-Skelettsystems.

BACKGROUND: Orthopedic rehabilitation is a major entity in rehabilitation. Due to coming demographic changes and its challenges concerning mobility of elderly patients it will increase. The criticism on orthopedic rehabilitation in Germany focuses on its missing evidence in therapeutic eff ectiveness especially in chronic low back pain. This overall-criticism is actually no more valid as there are a number of studies showing eff ectiveness of orthopedic treatment in rehabilitation if psychosocial comorbidities are respected and treatment is focussed on occupational training and eintegration. GOALS: This overview describes the actual situation in orthopedic rehabilitation and its research. RESULTS: The need for orthopedic rehabilitation will increase over the next years due to demographic changes. Important fi elds in orthopedic rehabilitation research are chronic low back pain, new rehabilitation models with focus on occupational reintegration, rehabilitation in elderly and following joint surgery as well as the analysis of health-care-system changes due to disease related groups.

[Goal setting in inpatient medical rehabilitation: exploring the current practice]. / Reha-Zielvereinbarungen - gegenwärtige Praxis in der stationären medizinischen Rehabilitation.

OBJECTIVE: Goal setting is regarded as a key element in the rehabilitation process. Information about current goal setting practice is limited. However, there is potential for further improvement, e. g. as far as patient participation in the goal setting process is concerned. The study reports results of a survey on the current practice of goal setting in medical rehabilitation, focusing on development potential. The study examines acceptance and requirements for goal setting as well as patients' and professionals' experiences regarding goal setting during the rehabilitation process, with an emphasis on patient participation. METHODS: A total of n=40 rehabilitation professionals and n=210 inpatients with a diagnosis of chronic back pain, diabetes mellitus type 2 or coronary heart disease were surveyed at six rehabilitation centres using a questionnaire. Questionnaires contained predominantly closed-ended items regarding the current practice of goal setting. Several items were identical for both groups. In addition to the quantitative evaluation by means of frequency analyses free text data were evaluated. RESULTS: Rehabilitation professionals saw various benefits in goal setting with patients. Many professionals experienced patients to have personal goals for their rehabilitation, and most of them believed that patient participation in goal setting is possible. Also, barriers and requirements for goal setting were identified. A consistent concept for goal setting, involvement of and exchange between the different occupational groups and an elaborate handling of information in the context of goal setting seem to be realised at least partially. Professionals and patients reported similar frequencies of talks on goal setting at different times during the rehabilitation course. Patient participation seems to be realised to some extent but not comprehensively. The results show slight discrepancies between patients' and professionals' statements. DISCUSSION: Current practice of goal setting in inpatient rehabilitation of patients with the diagnoses named above is altogether on a relatively advanced level in the rehabilitation centres taking part in the study. The study identifies potential for development concerning a comprehensive implementation of goal setting, the realisation of patient participation, goal documentation and their integration into rehabilitation. Moreover, deeper involvement of the rehabilitation team and a stronger conceptual integration of the subject within the centres seem desirable. This can be taken up within the scope of interventions.

[Patient-doctor interaction in rehabilitation: is there a relationship between perceived interaction quality and long term treatment results?]. / Patient-Arzt-Interaktion in der Rehabilitation: Gibt es einen Zusammenhang zwischen wahrgenommener Interaktionsqualität und langfristigen Behandlungsergebnissen?

OBJECTIVES: A body of evidence suggests that good interaction is crucial for high-quality medical practice and that it has a considerable impact on treatment outcomes. Less is known about the role and significance of doctor-patient interaction in rehabilitation. The study's aim was to capture perceived quality of doctor-patient interaction in rehabilitation by a rating instrument (P.A.INT-Questionnaire) and to examine the relationship between perceived quality of interaction and long-term treatment outcomes. METHODS: Referring to the approach of Bensing (1990) and Rogers (1972) we defined "quality of interaction" in terms of 3 dimensions: (1) affective behaviour, i. e., empathy, positive regard and coherence; (2) instrumental behaviour: providing and collecting information, structuring and reinforcement; (3) participation and involvement of patients. 2 parallel versions of the Questionnaire were developed for patients and physicians. 7 rehabilitation clinics in north-western Germany participated in the multi-centre study. 61 doctors and their 470 patients evaluated both their shared dialogues upon admission, discharge and at least one ward round. Furthermore, patients rated their health status on admission (t0), discharge (t1) and 6 months after discharge (t2) using the IRES-3 (Indicators of Rehabilitation Status Questionnaire Version 3). RESULTS: (1) Comparisons of patient and physician evaluations on admission revealed the following: Affective quality of contact (empathy and coherence) was rated positively and without discrepancies by both patients and physicians. On the other hand, instrumental behaviour (information and structuring) was rated less positively by patients than by physicians. (2) Patients who rated the dialogue on admission more positively showed stronger treatment effects with respect to pain, to anxiety and depression 6 months after discharge. Also disability days decreased about 40% stronger in the group of positive raters. (3) Patient ratings of quality of interaction showed low but significant correlations with patient-related aspects like coping with disease, health-related knowledge and former positive experiences with physicians. A stepwise regression analysis revealed that interaction quality seems to contribute to enhanced treatment results independently of patients' competences. DISCUSSION: Our results suggest a positive relationship between perceived interaction quality as defined by the P.A.INT-Questionnaire and treatment effects 6 months after discharge. Comparisons of patient and physician evaluations showed that physicians seem to be successful in building relationships on the affective level but less successful on the instrumental level (i. e., information, structuring and reinforcement). Our data underline the importance of interaction quality for the success of rehabilitation and thus the importance of specific skills such as providing and collecting information, recognizing patients' concerns and goals as well as reinforcement of health-related action. This is especially important when knowledge of disease and coping with disease on patients' side is poor. Interaction quality seems to contribute to better treatment results independently of patients' competences.

[A comparison of multimodal programmes of patient education in the rehabilitation of chronic low back pain]. / Multimodale Interventionsprogramme in der Rehabilitation von Patienten mit chronischen Rückenschmerzen--Ein Vergleich.

There is growing evidence for the effectiveness of multimodal intervention concepts for chronic low back pain in the international literature, and accordingly several German rehabilitation programmes for the treatment of chronic low back pain patients have been developed. Focus of this paper is to describe and compare frequently used German multimodal intervention programmes for in- and outpatient rehabilitation of patients with chronic low back pain. Programmes were chosen by searching the most relevant online resources as well as the online pages of Deutsche Rentenversicherung and Zentrum Patientenschulung during September 2008. Keywords guiding the search were: Patientenschulung, Rückenschmerzen, Manual, psychologische multimodale Interventionskonzepte, Rehabilitationsprogramm, psychology, intervention, low back pain, manual and therapy. By this means, six manually supported multimodal rehabilitation programmes for the in- and outpatient therapy of patients with chronic back pain could be identified: Göttinger Rücken-Intensiv-Programm (GRIP), the psychological programme for chronic head- and low back pain, the Münchner Rücken-Intensiv-Programm (MRIP), Back to Balance, Arbeiten und Leben--Back to Balance (ALEBABA) und Rückenfit: Lebenslust statt Krankheitsfrust. These programmes are depicted and compared with regard to their potentials and limitations in supporting the rehabilitation process of patients with chronic low back pain. While comparing the programmes, a number of similarities between them can be detected, as well as pronounced differences, e. g., regarding settings and complexity. In most programmes, lack of appropriate evaluation studies and lack of aftercare turn out to be critical aspects.

[Long-term efficiency of orthopedic rehabilitation in chronic back pain--the integrative orthopedic psychosomatic concept (IopKo)]. / Nachhaltigkeit orthopädischer Rehabilitation bei chronischen Rückenschmerzen--Das Integrierte orthopädisch-psychosomatische Behandlungskonzept (IopKo).

UNLABELLED: Chronic diseases of the musculoskeletal system rank first as causes of early retirement in Germany. Therefore orthopaedic rehabilitation has to identify patients with work-related problems and to promote return to work through differential treatment and vocational counselling. In the framework of the IopKo-Project such measures were developed and evaluated. These measures encompass: (1) an intensive and multiprofessional diagnostic pathway which allows early detection and treatment of mental disorders and job related problems; (2) homogeneous treatment groups based on multiprofessional diagnostics; (3) differential treatments, among these a multidisciplinary programme for patients with chronic low back pain or high risk of chronification (Rückenfit); (4) interactive training modules which mediate principles of performance and disability expertise, the legal bases of retirement pensioning, and measures to support occupational rehabilitation; and (5) a work hardening training programme. METHOD: To evaluate the effects of these measures in comparison to a control group with usual care, a prospective longitudinal study was conducted. A total of 307 patients were assigned to the multidisciplinary in-patient treatment programme, whereas 176 patients in the control group had a standard rehabilitation programme. RESULTS: The results show positive moderate and strong effects in the intervention group concerning function, pain, psychic strains as well as the number of sick days and return to work rates 10 months after discharge. The effects in the intervention group exceeded the effects achieved in the control group. PATIENTS WITH HIGH RISK OF CHRONIFICATION: Beside the full sample, a subgroup of patients with chronic pain or high risk of chronification was analyzed, who had received a multidisciplinary functional restoration treatment. Also for this subgroup we found moderate and strong effects of treatment for function, psychic strains and sick days superior to those in the control group. CONCLUSION: By this study we were able to show that orthopedic rehabilitation in a multimodal and multidisciplinary setting with a focus on activating and motivating therapy can have sustainable positive effects on pain, function and psychic well-being as well as on economic parameters. We interpret these persistent and superior effects in the treatment group (1) as a result of multiprofessional diagnosis and assignment which helps to subdivide the inhomogeneous group of patients with unspecific back pain into more homogeneous and thus more effective subgroups, (2) as a result of increased motivation by closed treatment groups, (3) as a result of intense and multilevel counselling of work related problems, (4) as a result of work hardening modules, and (5) as a result of direct and efficient treatment of psychic strains. The results also demonstrate the significance of inpatient rehabilitation, which will be efficient if differential treatment - adequate to the problems of the patient - is offered.

[Multidisciplinary orthopedic rehabilitation program in patients with chronic back pain and need for changing job situation -- long-term effects of a multimodal, multidisciplinary program with activation and job development]. / Integriertes Orthopädisch-Psychosomatisches Konzept zur medizinischen Rehabilitation von Patienten mit chronischen Schmerzen des Bewegungsapparates -- Langfristige Effekte und Nachhaltigkeit eines multimodalen Programmes zur Aktivierung und beruflichen Umorientierung.

BACKGROUND: According to a recent review by Hüppe and Raspe effects of multidisciplinary treatment programs for patients with chronic low back pain in Germany seem to be rather weak and not to have persisting effects. Factors which could counteract possible benefits of treatment are, among others, psychic and job-related stresses and strains persisting after treatment. A multidisciplinary, in-patient treatment program for patients with chronic low back pain, therefore, was amended by multidisciplinary diagnosis and assignment and measures to support vocational solutions. METHOD: To evaluate the effects of the multidisciplinary program in comparison to a control group with the usual care, a prospective longitudinal study was conducted. 307 patients were assigned to the multidisciplinary in-patient treatment program, whereas 176 patients with comparable complaints had the standard rehabilitation program. Besides the full sample, we analyzed a subgroup of patients with chronic low back pain. RESULTS: We found positive moderate and strong effects in the intervention group concerning function, pain, psychic strains as well as the number of sick days and return to work rates 10 months after discharge. Effects in the intervention group exceeded the effects achieved in the control group. Beside the full sample, we analyzed a subgroup of patients with chronic low back pain, who received an intense activating group treatment. Also in this subgroup we found moderate and strong effects of treatment superior to those in the control group for function, psychic strains and sick days. CONCLUSION: We attribute these persisting and superior effects in the treatment group to an efficient treatment of occupational and psychic problems as well as to more homogeneous treatment groups attained by a multidisciplinary diagnosis and team-based assignment. They also show the significance of in-patient-treatment which is effective, when -- based on multidisciplinary diagnosis -- differential treatment groups can be formed.

[Effect of goal setting on information processing in letter comparison tasks]. / Zur Wirkung von Zielsetzungen auf die Informationsverarbeitung bei Buchstabenvergleichsaufgaben.

In two laboratory experiments (N1 = 84, N2 = 20) the impact of goal setting on information processing (perception) in letter-matching tasks was examined. It was expected that setting difficult goals for reaction times improves performance because identification and especially semantic classification of letters should be speeded up under goal-setting instructions. Three findings can be emphasized. (1) Current models of simultaneous letter matching are incomplete because they do not account for differences in reaction time based on alphabetic variations (lower case vs. upper case letters) within a pair of letters that are largely independent of real letter sizes. (2) In both experiments and for all types of letter pairs (AA, Aa, Ab AB), goal-setting effects are found as expected. In addition, the explanation that these effects are due to a speed-accuracy trade-off can be excluded. (3) Moreover, in some conditions goal-setting effects are also influenced by special features of letter pairs. Specifically, goal-setting effects are especially strong for letter pairs in which the right letter was enlarged and in which alphabetic differences and semantic differences within pairs call for opposite answers (Aa, AB). Based on the overall pattern of results, it is concluded that difficult goals lead to a general facilitation of processes in visual perception and, in addition, to a reduction of stimulus-induced, performance-delaying inhibition processes if linguistic information is processed predominantly in the left hemisphere.