[Chronic pain in general practice : Results from pain specialists]. / Chronischer Schmerz in der Praxis : Daten aus dem niedergelassenen Bereich.

BACKGROUND: There is currently a lack of data on chronic pain in general practice. METHODS: Over a period of 2 years, data from 12,271 patients visiting a pain specialist on an outpatient basis were collected. All patients had documented their pain history (German pain questionnaire) via tablet/computer into a databank. RESULTS: Data from 12,246 patients from 30 pain clinics could be evaluated. The proportion of women was higher (67%). The majority of patients suffered from back pain (52%). The majority of patients were treated with injections (73%), and the majority of physicians were orthopedic surgeons (71%). A minority of patients had received psychological treatment (< 30%). CONCLUSION: Comprehensive pain documentation by the patients themselves is possible by means of a computer-based program. Back pain is the main problem in patients visiting a pain specialist. Invasive methods are the mainstay of treatment approaches. The psychosocial background of chronic pain seems to be underestimated in the treatment.

[Euthanasia and physician-assisted suicide : Attitudes of physicians and nurses]. / Tötung auf Verlangen und assistierter Suizid : Einstellung von Ärzten und Pflegekräften.

BACKGROUND: The current debate about end-of-life decisions in Germany focuses on physician-assisted suicide (PAS). However, there is only limited information available on physicians' attitudes towards euthanasia or PAS, and no data on nurses' attitudes. OBJECTIVES: The aim is to explore attitudes of physicians and nurses with a special interest in palliative care and pain medicine using a case-related questionnaire. METHODS: An anonymous questionnaire, consisting of eight questions, was distributed to all participants of a palliative care congress and a pain symposium. The questions focused on two scenarios: (1) a patient with an incurable fatal illness, (2) a patient with an incurable but nonfatal illness. The question was: Should euthanasia or physician-assisted suicide (PAS) be allowed. In addition, the participants were asked what they wanted for themselves if they were the patient concerned. RESULTS: A total of 317 questionnaires were analyzed; the return rate was 70 %. The general support for euthanasia and PAS was high: 40.5 % supported euthanasia in case of a fatal illness ("definitely…", "probably should be allowed"), 53.5 % supported PAS. The support decreased in case of a nonfatal illness; however, it increased when the participants were asked about their attitudes if they were the patient concerned. Nurses were more open towards euthanasia and PAS. In physicians the rejection of PAS was directly related to a higher level of qualification in the field of palliative care. CONCLUSION: The fact that nurses had a more positive attitude towards euthanasia and PAS and that all respondents accepted life-ending acts for themselves more than for their patients hints to still existing severe deficits in Germany.

[Limits of pain treatment: medical and judicial aspects]. / Grenzen der Schmerztherapie: Medizinische und Juristische Aspekte.

Medical principles of pain treatment are generally in line with the judicial principles. To relieve pain is one of the fundamentals of medicine and this has also been acknowledged by the Federal Court in Germany. It is criminal bodily harm, when a physician denies a possible pain treatment. Whereas courts clearly see an obligation to basic and continuing education in pain diagnosis and therapy, pain is still not represented in the German licensing regulations for physicians. Only palliative medicine has been added to the obligatory curriculum. Very similar pain is not mandatory in many clinical disciplines leaving physicians without the needed knowledge to treat pain. The need for interdisciplinary treatment is not yet acknowledged sufficiently, although meanwhile chronic pain is regarded as a bio-psycho-social illness.Since 2009 the advance directive is regulated by law. However, still many physicians are unaware that not only the position of the patient but also of the relatives have been strengthened. In 2010 the Federal Court has pronounced a judgment allowing "passive euthanasia" in certain conditions but prohibiting any active handling even in line with the patient's will. This is also in line with the European Human Rights Convention. The judicial unpunished assisted suicide has provoked an ethical discussion within the medical profession. However, what is not illegal is not automatically accepted as ethical handling for physicians. Palliative medicine is at least one alternative in this discussion.

[How should anesthesiologists perform ultrasound examinations? Diagnostic use of ultrasound in emergency and intensive care and medicine]. / In welcher Weise sollte ein Anästhesist sonographieren können? Diagnostischer Einsatz des Ultraschalls in der Akut- und Intensivmedizin.

Ultrasound imaging has attained great significance as a tool for diagnostics in emergency and intensive care medicine. The major advantages of this technique are its instantaneous bedside availability and the possibility to perform repeatable examinations. These advantages are based on recent developments, such as portable ultrasound devices offering excellent imaging quality as well as a quick-start-function. Ultrasound imaging in critically ill patients is frequently performed under pressure of time depending on the current acute physical state. All standard examinations in echocardiography, vascular, abdominal and thoracic ultrasound scanning can be applied in these patients. Based on the clinical scenario the duration of examinations may vary from seconds during cardiopulmonary resuscitations to time-consuming repeated scanning. The transition from basic to subject-specific detailed examinations is flowing and has to be adjusted to local conditions. In the field of emergency and intensive care medicine the technique used is whole-body sonography. The goal is to classify the patient's present physical state and to define a targeted therapeutic approach. The characteristics of whole-body sonography are similar to the field of anesthesiology which is an interdisciplinary one. Currently, these characteristics deserve more attention in training in sonography.

[Success of treatment in higher stages of pain chronification as well? An evaluation of the Mainz pain staging system based on the QUAST-analysis sample]. / Behandlungserfolg auch bei höherer Schmerzchronifizierung? Eine Auswertung des Mainzer Stadienmodells auf Basis der QUAST-Analysestichprobe.

BACKGROUND: More than 10 years ago Gerbershagen gave a pessimistic prognosis for treatment success in patients with higher stages of pain chronification. To date only few studies concerning this statement exist and the results are inconsistent. The objective of this study was to evaluate the prognostic validity of the Mainz pain staging system (MPSS) in a large multicenter sample. It was assessed whether effects of treatment in patients with higher stages of pain chronification are less than those in other patients. Of further interest was whether treatment success is related to different outcome measures. METHODS: A total of 1,461 patients with the pain syndromes headache, neuropathic pain, back pain or algiomuscular pain and arthralgia were enrolled in the analysis. They were selected from the QUAST analysis sample which includes patients from 19 cooperating pain clinics. All patients had completed the German pain questionnaire prior to pain treatment and these data were compared with the last available questionnaire during the course of treatment. Outcome measures were pain intensity, psychological disability scores and patient global impression of success (PGIS). RESULTS: Analysis showed a significant improvement of all outcome measures in every MPSS stage. The greatest improvement was noted for pain intensity whereas outcome variables regarding mental health revealed the lowest improvement. Compared with patients with low pain chronification, changes in pain intensity were smaller for patients with the highest MPSS stage III but even in these patients the strength of effect was more than 0.80. About 50% of all patients showed a reduction of pain intensity of 2 or more points on an 11 point numerical rating scale and 46.6% of patients with a MPSS stage III showed this improvement. Importantly, PGIS was independent of the stage of chronification. Nearly 45% of all patients evaluated the treatment success as good or very good. CONCLUSIONS: According to the view of the patients, treatment in specialized pain centres is successful even in the highest stage of pain chronification. This notwithstanding, success of treatment must not be confounded with the efficacy of an intervention. It has to be noted that the results of the current study do not allow conclusions regarding efficacy of treatment.

[Validation of an advance directive]. / Validierung einer Patientenverfügung.

BACKGROUND: German Legislation has defined the legal significance of advance directives (AD). Nevertheless, many precast ADs are of limited help in clinical decision making. Empirical results are rare and controversial. The SUPPORT study showed that precast ADs had a tendency to being ignored. Value-based AD proved to be of help in the interpretation of patients' wills by physicians. We therefore investigated whether a value-based AD that can be individualized with the help of a check-box-system is a valid instrument of communicating the patient's preferences. This is the first validation of an AD. MATERIAL AND METHODS: In our study we evaluated the acceptance and practicability of an AD. Questionnaires and the AD itself were handed out to patients, relatives, and members of the nursing and medical staff. All were asked to fill out the AD, mark all unclear passages, make amendments to the AD if wanted and finally were asked to answer a questionnaire regarding the AD. The level of significance was defined at 5%, meaning that every "unwanted" answer exceeding 5% or passages with more than 5% of the total remarks were analyzed and it was checked whether changes to the AD should be made. RESULTS: The return rate was 64.8% (201 of 310). The results were highly positive for the items "understandable" (81,6%), "clarifying" (65,7%), "helpful" (76,1%), and "sensible" (75,1%). 70% of patients and relatives stated that they were able to express personal wishes and values with this AD, as well as a majority of the medical staff (44% vs. 30%). The discrepancy between the groups was significant (ChiSq=13.11, p<.001). All paragraphs of the check-box-system were validated as understandable and clear in intention. Major concerns were the inability of expressing own wishes and values (by 16,4% of all participants) and the fear of later alterations (15,4%). According to the findings and the evaluations the AD was modified. DISCUSSION: The value-based AD which is routinely used in a university hospital and which can be individualized by a check-box-system was broadly accepted by the test subjects and showed highly positive results with respect to the analyzed items. Only minor changes were derived from our study to hopefully raise its acceptance even more. The discrepancy between patients, relatives and the medical staff concerning the possibility to express one's wishes and values was surprising and in contradiction to former findings. However, our study cannot answer whether the higher level of distrust among medical staff can be explained by negative professional experiences. CONCLUSION: The investigated AD with a check box system seems to be an adequate instrument to communicate patient's wishes and directives.

[Laser acupuncture for chronic back pain. A double-blind clinical study]. / Laserakupunktur bei chronischen Rückenschmerzen. Eine klinische Doppelblinduntersuchung.

BACKGROUND: The goal of this study was to evaluate the efficacy of laser acupuncture for the clinical picture of chronic back pain under everyday conditions using a randomized, double-blind, placebo-controlled study design. A further aim was to analyze to what extent placebo effects also influence the outcome of acupuncture under these conditions. PATIENTS AND METHODS: The study included male and female patients with chronic back pain (lasting longer than 6 months) aged between 30 and 77 years with a pain score of at least 5 on a visual analog scale. The main criterion was achieving alleviation of pain by at least 50% 3 months after the start of treatment. The assessment tools used were the Von Korff questionnaire supplemented by the FFbH, FABQ, and SF-12. In addition, the participants were questioned about whether they perceived anything during the treatment and how certain they were that they had received treatment with active or inactive lasers. RESULTS: A total of 111 patients were included in the study and were treated according to the randomization list in two groups each consisting of 51 subjects. The study was completed as scheduled by 102 participants. Analysis of the primary outcome measure, improvement of the pain score by more than 50% over baseline, revealed improvements in both treatment groups between the time points used for measurement. The placebo group exhibited better levels than the group that received laser treatment. No efficacy advantage of laser acupuncture over placebo treatment could be determined. CONCLUSION: It was possible to completely blind the acupuncture forms with the study design employed. Perhaps the consistent exclusion of nonspecific treatment effects contributed to this result. It cannot be ruled out that the effects of acupuncture are based on a strong placebo effect.

[Chronic pain in German medical practices. Current demands placed on the primary health care system due to pain prevalence]. / Chronische Schmerzen in deutschen Facharztpraxen. Die aktuelle Inanspruchnahme des ambulanten Gesundheitssystems anhand der Prävalenz von Schmerzen.

BACKGROUND: The prevalence of chronic pain as related to the supply situation in primary care has been investigated insufficiently. PATIENTS AND METHODS: A questionnaire was used to collect data of 1,201 patients in 6 different specialists' practices (general medicine, surgery, internal medicine, neurology, oncology, orthopaedics). The questions posed related to socio-demographic facts, pain characteristics, psychosocial effects, previous therapies and their subjective effectiveness. RESULTS: Pain was the reason for consulting a doctor in nearly 50% of the patients; 40% of all respondents complained about chronic pain, defined as recurrent or constant pain lasting longer than 6 months. As many as 90% of these subjects reported psychosocial impairment due to chronic pain and 25% evaluated their therapies as ineffective. CONCLUSION: Chronic pain is a major problem in primary care. The high level of suffering and the enormous socioeconomic impact on public health demand consequences. Improvements in undergraduate and postgraduate training are urgently required for both an adequate pain treatment and the prevention of chronic pain.

[Dealing with (no longer) needed narcotics in the outpatient palliative care setting]. / Umgang mit (nicht mehr) benötigten Betäubungsmitteln in der ambulanten Palliativversorgung.

BACKGROUND: For the provision of home care for dying patients the availability of potent pain medication is essential. The aim of this survey directed at community palliative care physicians was to assess and evaluate the current situation of provision and supply of pain medication in the community palliative care setting, including hospices and specialised palliative care teams. MATERIAL AND METHODS: A total of 489 palliative care doctors were identified from registers held by the Practitioners Associations. These professionals received a letter requesting information about the provision of narcotics in ambulatory and community practice. The answers were evaluated and analysed with descriptive statistics. RESULTS: Of the 489 palliative care specialists, 208 (43%) responded. Almost all of the doctors (99%) considered the availability of a constant supply of narcotics as vital for their practice; 86.3% considered the service provided by public pharmacies as inadequate. Some incidents of flagrant mismanagement were reported. Only 11% of the doctors considered the transfer of narcotics from one patient to the other in hospices and retirement homes via a new narcotics prescription as practicable; 89% of the doctors judged this procedure to lack practicability. CONCLUSIONS: Despite the fact that the need for unrestricted opioid provision in specialised community palliative care is indisputable and recognised, the implementation is nevertheless hindered by a multitude of legal red tape. One solution to the problem would be the legalisation of emergency supplies of narcotics to be held by specialised facilities, such as hospices or specialised palliative care teams. This could, for instance, be implemented via the narcotics requisition form currently used for inpatient supplies in hospitals or for emergency services. Hospices and care homes must be enabled to receive their supplies directly without bureaucratic hindrance and without the need for renewed narcotic prescription.

[Characterization of chronic pain patients in German pain centers : core data from more than 10,000 patients]. / Patientenkollektiv deutscher schmerztherapeutischer Einrichtungen : Kerndaten von mehr als 10.000 Patienten.

BACKGROUND: In 1998 the board of the DGSS introduced a computerized documentation system named QUAST (quality assurance in pain therapy) building the foundation for a large, anonymous database that served as a data source for the statistical characterization of clinically relevant profiles of patients in German pain clinics. METHODS: A total of 10,054 data files collected between 1998 and 2004, including socio-demographic as well as psychometric and pain parameters were analyzed. RESULTS: The main pain diagnoses found in the database sample were back pain (37%), neuropathic pain (21.4%), soft tissue or arthralgia pain (19.5%) and headache (10.6%). The average duration of illness upon presentation at pain clinics was 7 years, nearly 20% contacted it within the first year. Of the sample, 43.8% of the patients were in the second chronicity stage and 39.0% in the third stage of the Mainz Pain Staging System (MPSS). Psychological measurements concerning despression, pain disability and quality of life indicated a great amount of psychological distress. Pronounced differences between main diagnostic groups were observed not only for psychological factors but also for direct pain parameters. CONCLUSIONS: The documented data differ from other population-based data collections. In contrast to common belief there are a considerable number of patients who find access to specialized pain therapy institutions at an early stage of their illness. The hitherto regular use of generic, syndrome-overlapping diagnosis and treatment tools should be reconsidered taking into account the differences found between the main pain diagnosis groups. Lastly, this analysis provides current data on the psychological state of chronic pain patients showing a high degree of psychological distress and underlying the need of psychotherapeutic interventions in the treatment of chronic pain patients.

[Pain and quality of life for living donors after nephrectomy]. / Schmerz und Lebensqualität nach Nephrektomie bei Lebendspendern.

BACKGROUND: This survey focussed on chronic postoperative pain and impairment of quality of life after living donor nephrectomy. METHODS: Out of a total of 82 donors 58 (71%) were examined using the Chronic Pain Grade (CPG) by von Korff and Short-Form 12 (SF-12). RESULTS: Of the donors 34% suffered from chronic postoperative pain 22 months (range 9-57 months) after nephrectomy and in 55% of these cases the pain interfered with daily life activities. The quality of life was almost comparable with those of the average German population, but was reduced by chronic postoperative pain particularly with respect to the mental state. CONCLUSION: Measures have to be taken to prevent chronic postoperative pain and donors should be encouraged to express their pain to ensure an adequate pain therapy.

[Chronic pain management]. / Therapie chronischer Schmerzen.

Pain is one of the major complaints leading to doctor visits. Therefore basic knowledge of frequent pain diagnoses and possible treatment approaches is essential. Numerous medical and interventional therapeutic options are available for causal or symptomatic treatment of pain. The treatment of neuropathic pain is often difficult and demands special knowledge. Antidepressants like amitriptyline and anticonvulsive drugs are the first choice in these cases. Also interventional approaches are useful, such as spinal cord stimulation for angina pectoris. For the treatment of complex regional pain syndrome and phantom pain the use of mirror feed-back is a new effective method for pain relief. The only way to prevent from development of chronic pain is the early and effective treatment of acute pain.