[On the interdisciplinary S3 guidelines for the treatment of chronic idiopathic tinnitus]. / Zur interdisziplinären S3-Leitlinie für die Therapie des chronisch-idiopathischen Tinnitus.

INTRODUCTION: Tinnitus is a frequent symptom, which, particularly in combination with comorbidities, can result in a severe disease-related burden. Chronic idiopathic tinnitus (CIT) is the most frequent type of tinnitus. A considerable number of treatment strategies are used to treat CIT-for many of which there is no evidence of efficacy. In order to enable scientific evidence-based treatment of CIT, German interdisciplinary S3 guidelines have recently been constructed for the first time. Here we present a short form of these S3 guidelines. MATERIALS AND METHODS: The guidelines were constructed based on a meta-analysis of the treatment of chronic tinnitus performed by the authors. Additionally, a systematic literature search was performed in the PubMed and Cochrane Library databases. Furthermore, a systematic search for international guidelines was performed in Google, as well as in the Guidelines International Network and National Guideline Clearinghouse (USA) database. Evidence was classified according to the Oxford Centre for Evidence-Based Medicine system. RESULTS: According to the guidelines, alongside counselling, manualized structured tinnitus-specific cognitive behavioral therapy (tCBT) with a validated treatment manual is available as evidence-based therapy. In addition, the guidelines recommend concurrent treatment of comorbidities, including drug-based treatment, where appropriate. Particularly important is treatment of anxiety and depression. Where a psychic or psychiatric comorbidity is suspected, further diagnosis and treatment should be performed by an appropriately qualified specialist (psychiatrist, neurologist, psychosomatic medicine consultant) or psychological psychotherapist. In cases accompanied by deafness or hearing loss bordering on deafness, cochlear implants may be indicated. CONCLUSION: No recommendations can be made for drug-based treatment of CIT, audiotherapy, transcranial magnetic or electrical stimulation, specific forms of acoustic stimulation or music therapy; or such recommendations must remain open due to the lack of available evidence. Polypragmatic tinnitus treatment with therapeutic strategies for which there is no evidence of efficacy from controlled studies is to be refused.

[Influence of cognitive-emotional processing on pain and disability. A psychobiological perspective]. / Einfluss von kognitiv-emotionalen Prozessen auf Schmerz und Funktionsbeeinträchtigung. Eine psychobiologische Perspektive.

In the context of the biopsychosocial pain concept and on the basis of empirical evidence those cognitive traits and mechanisms are described that have reliably been found to be potent moderators of pain and disability. Expectations of patients which result in placebo or nocebo effects as well as more complex belief patterns influence subjective pain severity as well as disability. Especially beliefs which relate to self-control, self-efficacy or its counterpart helplessness can distinctly moderate pain, lead to an increase or mitigation of pain intensity and associated disability. The impact of most of these cognitive factors, such as catastrophizing, low self-efficacy, certain pain beliefs, low acceptance or fear of pain can be integrated into the general stress coping model. It denominates situational appraisal and self-appraisal processes beside actual coping behaviors as the main psychological factors influencing severity of pain and related disability.

[Headache in children and adolescents. Epidemiology, biopsychosocial correlates, and psychological treatment approaches]. / Kopfschmerz bei Kindern und Jugendlichen. Epidemiologie, biopsychosoziale Korrelate und psychologische Behandlung.

EPIDEMIOLOGY: An abundance of studies have consistently shown that headache is the most prevalent pain in children and adolescents. Weekly headache is experienced by more than 10 % and is distinctly more frequent in girls. The number of headache-affected youths with high disability is lower than expected (~ 4 %). THE ASSOCIATION WITH BIOPSYCHOSOCIAL FACTORS: Headache is associated with pain in other body sites, thus multiple pain is experienced more often than isolated headache. Various somatic symptoms and even chronic diseases are also correlated with headache. Headache in parents carries a high risk of also occurring in their children. Various other psychosocial factors such as dysfunctional psychological traits are closely linked with headache, the most prominent being internalizing symptoms. However, externalizing symptoms also correlate with headache. Pain catastrophizing, as well as somatosensory amplification and anxiety sensitivity, have been shown to characterize individuals with headache. Features of the social environment, such as life events, school, as well as family stressors and socioeconomic parameters, are among the risk factors. PSYCHOLOGICAL INTERVENTIONS: Psychological interventions such as biofeedback, relaxation, and cognitive-behavioral training have proved their efficacy in headache treatment according to several meta-analyses. The latter has also been conducted in group settings and more recently in self-management focused trainings using electronic media. They mainly aim at the prevention of further headache episodes. The goal of this training is the strengthening of self-efficacy beliefs and active coping strategies. It is proposed that these competencies could contribute to the successful long-term prevention of an adverse course of headache into adulthood.

[Psychological therapy of migraine: systematic review]. / Psychologische Therapie der Migräne: Systematische Übersicht.

This review summarizes the various forms of behavioral treatment of migraine which could demonstrate empirical efficacy. The main unimodal kinds of treatment are thermal and electromyography (EMG) biofeedback training and progressive muscle relaxation. The various relaxation techniques do not differ in their efficacy in treating migraine. On average a reduction in migraine frequency of 35-45 % is achieved. The mean effect sizes (ES) of various biofeedback techniques are between 0.4 and 0.6. Cognitive-behavioral treatment is applied as a multimodal treatment and on average achieves an improvement in migraine activity by 39 % and an ES of 0.54. All behavioral procedures can be used in combination or as an alternative to drug prophylaxis with comparable success. A combination of pharmacological and behavioral treatment can achieve additional success. There is strong evidence for the clinically significant efficacy of all forms of behavioral treatment in childhood and adolescence. There are no signs of differential indications.

[Lifting capacity with low back pain : Discrepancy between self-rated and real lifting capacity in patients with back pain and pain-free controls]. / Hebefähigkeit bei Rückenschmerzen : Diskrepanz zwischen Selbsteinschätzung und tatsächlich gezeigter Hebefähigkeit bei Rückengesunden und Patienten mit Rückenschmerzen.

BACKGROUND: The fear-avoidance model implies that in situations with physical demands patients with back pain will overestimate the demand and underestimate their own capacities. PATIENTS AND METHODS: A total of 71 patients with back pain and 48 pain-free control subjects carried out a standardized lifting test with a preceding estimation of their lifting capacity. RESULTS: In both groups the self-estimation and real lifting capacity were in concordance for most group members with patients showing less disconcordance than controls. In the control group 35% of the subjects even underestimated their lifting capacity, which was the case in only 14% of the patients. Patients more frequently overestimated their capacity than pain-free controls (14% vs. 2%). Within the patients subgroups could be identified where patients in general either underestimated or overestimated their own capacity. A comparison between the groups demonstrated significant differences in pain intensity, fear avoidance beliefs and effort. CONCLUSION: As an explanation for these unexpected results it can be hypothesized that in cases of back pain, patients' attention is focused on pain-relevant issues which enables a more realistic estimation of their lifting capacity.

Self-report of headache in children and adolescents in Germany: possibilities and confines of questionnaire data for headache classification.

The aim of this study was to estimate prevalence rates of different types of primary headache in 9- to 14-year-old children in a population-based sample. Case definition was based on International Classification of Headache Disorders (ICHD) criteria. The possibility of implementing these criteria within a questionnaire format, which has been regarded as problematic by some authors, was the main focus of the study. A questionnaire was sent to children and adolescents in 6400 randomly drawn families in southern Lower Saxony. Valid questionnaires were returned by 61.1% of the sample. The overall prevalence rate for tension-type headache (TTH) (criteria C and D) was 17.6% and for migraine (criteria B, C and D) 13.1%. Despite the use of abridged criteria for headache classification, 35.5% of all children reported headache that could not be classified using the ICHD criteria. The response behaviour of these children indicated that they had difficulties reporting symptoms that were defining for migraine or TTH. The classifiability of headache does not seem to be dependent on age or frequency of headache, but rather on the number of 'I don't know' answers given regarding headache characteristics. It is likely that studies reporting prevalence rates that are limited to migraine and or TTH diagnoses underestimate the true prevalence of headache in children and adolescents.

One-year course of paediatric headache in children and adolescents aged 8-15 years.

The aims of the present study were the assessment of headache (HA) prevalence in German children and adolescents in the second year of a 4-year longitudinal study and the analysis of headache status change from year 1 to year 2. The original sample consisted of 8800 households with a child aged 7-14 years. A total of 4159 households responded in both year 1 and year 2, yielding 3984 valid parent questionnaires. Data regarding various aspects of the child's HA history and general health were gathered via mailed questionnaires from the parents. Of the households returning valid parent questionnaires at survey 2, 48.9% reported their child to have experienced headaches during the previous 6 months (53% at survey 1). Weekly HA was reported for 6.5% of the children, monthly or less frequent HA for 16.5% and 25.9%, respectively. With regard to headache diagnosis, 55.0% of the children and adolescents with HA experienced tension-type HA (TTH) and 11.3% migraine with or without aura (M). For more than half of the children and adolescents with HA (57.0%) the frequency of head pain remained stable over the period of 1 year (i.e. same frequency category in years 1 and 2). Improved and worsened HA status regarding frequency of occurrence was found in 22.3% and 20.7% of the subjects, respectively. Thus, there was no definite trend towards an increase of HA episodes over the course of 1 year regarding the individual child or adolescent. The most stable type of HA was TTH.

Validation of the German version of the Fear-Avoidance Beliefs Questionnaire (FABQ).

Fearful avoidance of physical activities is a major factor in low back pain (LBP) and disability. In 1993 Waddell et al. developed the Fear-Avoidance Beliefs Questionnaire (FABQ) focusing on patients' beliefs about how physical activity and work affect LBP. The focus of our study was to analyse and validate the German version of the FABQ. Three-hundred and two consecutive LBP outpatients participating on a functional restoration programme filled in the FABQ. Factor analysis yielded three factors which accounted for nearly 65% of the total variance of the questionnaire. Whereas the factor 'physical activity' (8.9% of the variance) remained the same as in the English version, the second factor of the original version split into two: one related to, 'work as cause of pain' (43.4% of the variance) and the other to patients' assumptions of their probable return to work (11.8% of the variance). Both work-related subscales showed a good internal consistency (alpha = 0.89, resp. alpha = 0.94), whereas the consistency of the subscale 3 'physical activity' was only modest (alpha = 0.64). Test-re-test reliability score was fair to good for the whole scale (r = 0.87;n = 30). Regression analysis demonstrated that fear-avoidance beliefs account for the highest proportion of variance (35%) regarding disability in activities of daily living and work loss. Patients out of work demonstrated more fear-avoidance beliefs in comparison to those who were still working. It can be concluded that the German version of the FAQB is a reliable and valid instrument, but it shows a different factor structure from the original English version. The FABQ has been proven to identify patients with maladaptive beliefs which have to be focused on in proper treatment.

The physiological stress response and the role of cognitive coping in migraine patients and non-headache controls.

Our study investigated physiological response specificity and cognitive coping in migrainous patients during an achievement task situation. Thirty-three migrainous subjects and thirty-two non-headache controls were subjected to 40 min of demanding cognitive tasks and 20 min of recovery during which cranial and peripheral vasomotor responses were registered as well as electrodermal and myographic activity. Subjects of both groups were randomly assigned to two experimental conditions, a so-called 'spontaneous processing condition' and the 'positive coping treatment'. In this treatment condition subjects received a short training in the conscious use of positive self-statements in stress situations. Though a specific pattern of cranial vasomotor responses in migraine subjects could be verified by group statistics, this pattern was only found in very few individuals. Reliable differences between groups could not be identified in other physiological variables either. The hypothesis that the predicted cranial vasomotor specificity in migraine subjects correlates with negative cognitive coping habits in migraine subjects best revealed in the 'spontaneous processing' condition, was not corroborated. The treatment variation regarding coping produced somewhat paradoxical effects, more relaxed and positive self-evaluation (subjective level) and more arousal (physiological level). Results are discussed for their impact on the psycho-biological model of migraine.

The effect of exercise and induced expectations on visceral perception in asthmatic patients.

It is assumed that visceral perception of the asthmatic patient is not only influenced by the physiological response itself but also by cognitions, i.e. specific illness related attitudes and expectations. Thirty-two adult asthmatics were studied in a 2 X 2-factorial design to examine the effect of physical exercise due to an ergometer capacity test (set at a load of 40 and 80 watt respectively) and induced expectations about the consequences of this task on broncho-constriction. Two sets of instructions were used to induce anticipations of harmful and non-harmful consequences respectively. The following dependent variables were registered: airways resistance, skin resistance and visceral perception (rating of physiological changes). Before the experiment the habitual way of reacting to asthma-relevant cues in each subject was assessed. Only small effects of the different ergometer loads on physiological responding and no effects of the experimental variables on visceral perception were found using an analysis of variance approach. A covariance analysis, however, using the trait variable as covariate, demonstrated that the induced 'harmful' anticipation significantly intensified the perception of visceral changes and even had some influence on asthma-relevant physiological responding.

The management of chronic tinnitus: comparison of an outpatient cognitive-behavioral group training to minimal-contact interventions.

OBJECTIVE: Using a randomized group design, the efficacy of an outpatient cognitive-behavioral Tinnitus Coping Training (TCT) was compared to two minimal-contact (MC) interventions. METHODS: TCT was conducted in a group format with 11 sessions (total n=43). One MC [MC-E (education), n=16] consisted of two group sessions in which education on tinnitus was presented and self-help strategies were introduced. The second MC [MC-R (relaxation), n=16] comprised four sessions. Besides education, music-supported relaxation was suggested as self-help strategy and audiotapes with relaxing music were provided. Furthermore, a waiting-list control group was installed (WC, n=20). Data were assessed at baseline (pretherapy) and at posttherapy period. Only TCT was additionally evaluated at a 6-month and a 12-month follow-up. Several outcome variables (e.g., awareness of tinnitus) were recorded in a tinnitus diary. Tinnitus coping and disability due to tinnitus were assessed by questionnaires. Subjective ratings of improvement were also requested from the patients. Furthermore, inventories of psychopathology were given to the patients. RESULTS: Findings reveal highly significant improvements in TCT in comparison to the control group (WC). MC interventions do not differ significantly from each other, but are superior to WC in a few domains of outcome. Outcome in TCT is somewhat superior to combined MC interventions in two domains of data, but not regarding disability reduction. Effect sizes, nevertheless, indicate distinct differences in degree of improvement, with TCT achieving the best results. CONCLUSIONS: A sequential scheme for the treatment of chronic tinnitus is discussed on the basis of cost-effectiveness considerations.

Psychophysiological reactivity of migraine sufferers in conditions of stress and relaxation.

The assumption of a specific migraine-related psychophysiological response stereotype under conditions of stress, recovery and relaxation was examined in 37 migraineurs (non-headache state) and 44 normal controls. Two stressors were presented, industrial noise and a 'social discomfort' situation, each was followed by a recovery period. Relaxation was induced by verbal instructions accompanied by soft music. The following physiological measures were assessed: pulse volume amplitude (fronto-temporal and digital), skin temperature (fronto-temporal and digital) and skin resistance responses. Results showed no group differences in responses to the stressors. Physiological recovery from stress was delayed in migraineurs in the electrodermal parameter. During relaxation, migraineurs showed less digital vasodilation than the controls. Overall, physiological and subjective responses differed between the two stressors. The hypothesis of a specific vasomotor stress response stereotype in migraineurs could not be corroborated. The observed differences in relaxation and recovery were hypothesized. But the overall results are not easily explained on the grounds of a coherent model (e.g. elevated sympathetic arousal level).

The management of chronic tinnitus--comparison of a cognitive-behavioural group training with yoga.

Two non-medical treatment strategies for chronic idiopathic tinnitus were evaluated in a randomized control group design. A cognitive-behavioural tinnitus coping training (TCT) was developed and compared to yoga and a self-monitoring control condition. Forty-three chronic tinnitus patients, were assessed at baseline, directly after therapy, and at 3 months follow-up. For evaluation, differential psychoacoustic variables were registered, a tinnitus diary as well as the Tinnitus Questionnaire and different measures of general well-being were used. Statistical analyses showed effects favouring the TCT treatment in comparison to the control and yoga treatment. The TCT-treated patients reported more satisfaction with the training than the yoga group. Participants in the self-monitoring control group were treated either by TCT or yoga after a waiting period. The outcome in this group was even better than in the experimental groups while yoga again showed rather poor effects.

Incorporation of cognitive-behavioral treatment into the medical care of chronic low back patients: a controlled randomized study in German pain treatment centers.

Cognitive behavioral treatment has been incorporated into standard medical treatment procedures in German pain centers. Acceptance of the treatment by patients and outcome in terms of pain, coping, and disability was investigated. Components of the psychological treatment are education, relaxation and imagery, modifying thoughts and feelings, enhancement of pleasant activities, and training of good postural habits. The program was conducted in a group setting in accordance with a treatment manual and consists of 12 weekly 2.5-h sessions. A two-factor experiment with repeated measures on one factor was applied. Ninety-four consecutive patients with low-back pain were randomly assigned to an experimental group having a combined medical and cognitive-behavioral treatment, or to a control group with medical treatment only. Assessments were taken pre-treatment, post-treatment, and--in the treated group only--at a 6-months follow-up. At each assessment, patients kept a pain diary over a period of 4 weeks, and filled in self-report questionnaires. The sample consisted of 36 experimental and 40 control subjects at post-treatment. Experimental subjects reported less pain, better control over pain, more pleasurable activities and feelings, less avoidance and less catastrophizing. In addition, disability was reduced in terms of social roles, physical functions and mental performance. The results were maintained at follow-up. Patients who only received medical treatment showed little improvement. Data indicate that the program meets the needs of the patients and should be continued.

[Psychological stress on patients in tumor after-care after R0 resection of colorectal carcinomas]. / Die psychische Belastung von Patienten in der Tumornachsorge nach R0-Resektion colorectaler Carcinome.

In a prospective study 70 patients after curative resection for colorectal carcinoma were asked about the psychological strain in the follow-up program. Of these patients, 80.1% felt that they did the right thing and 70% were optimistic and confident regarding the follow-up examinations. Only 5 patients (7.1%) had no intention of keeping the follow-up appointment and 12 patients (17.1%) were thinking about recurrence. The patients were afraid of further examinations, and the majority (45 patients) hoped that further invasive examinations would not be necessary. Patients with a higher frequency of follow-up examinations did not report with more stress than patients fewer follow-up visits (P = 0.7 fisher exact). Older, single and female patients are special risk groups with a high level of psychological strain and should receive special attention within the follow-up (P < 0.08, fisher exact). In spite of the disappointing medical effectiveness of the regular follow-up program, psychological support in coping with cancer is the main result of regular follow-up visits to the hospital after curative resection of colorectal carcinoma and should be maintained.

Stress and the onset of sudden hearing loss and tinnitus.

Forty hospitalized patients with sudden hearing loss and tinnitus were compared to a control group (N = 28) of inpatients of an ear-nose-throat ward. They were similar in various background variables except for the kind of disorder itself. The main objective of our study was to test the hypothesis of stress as a predisposing risk factor in the development of sudden hearing loss and tinnitus. Thus, differences in life events and daily "hassles" were expected between groups, as were differences in coping styles, habitual worrying, and social support. The hypothesis of more frequent and more stressful life events and daily hassles was supported empirically. The dominant role of daily hassles, especially their stressfulness as a risk factor, was shown clearly. Those in the experimental group also reported more coping endeavors and more worrying. Social support had no discriminating function. The prospective part of the study aimed at the prediction of chronicity of sudden hearing loss and tinnitus (3 months after onset) by sociodemographic, psychological, and disease-associated variables. The strongest predictor of chronicity was the degree of well-being at the time of first assessment (soon after disease onset). Coping and a fatalistic locus of control also had some predictive power. Methodological limitations of the study are discussed.

Clinical features of chronic pain with neuropathic characteristics: a symptom-based assessment using the pain DETECT questionnaire.

BACKGROUND: In general, chronic pain is categorized into two mechanism-based groups: nociceptive and neuropathic pain. This dichotomous approach is questioned and a dimensional perspective is suggested. The present study investigated neuropathic characteristics in different syndromes of chronic pain. We also examined the association of neuropathic characteristics with various pain related and psychological variables. METHODS: From April 2010 to January 2012, 400 patients suffering from a chronic pain condition enrolled for multidisciplinary pain treatment were considered for inclusion in the study. Criteria for inclusion were age over 18 years and having chronic pain according to ICD-10 (F45.41) criteria. The pain DETECT questionnaire was used to assess neuropathic characteristics of pain. RESULTS: Thirty-seven percent of patients with different pain diagnoses demonstrated distinct neuropathic characteristics. The diagnostic groups for neuropathic pain, musculoskeletal pain and post traumatic or surgical pain showed the most neuropathic features. The level of depression, pain chronicity and intensity, disability and length of hospital stay were significantly higher in patients suffering from neuropathic symptoms. A high level of depression and pain chronicity as well as high intensity of pain explained most of the variance in the neuropathic scores. Disability and length of hospital stay significantly predicted neuropathic characteristics only when examined separately, but not if included in a common regression model. CONCLUSIONS: Any type of chronic pain may have more or less neuropathic characteristics. The pain-related parameters of high intensity and chronicity as well as negative affectivity and functional disability strongly correlate with neuropathic characteristics of pain.

Headache in German children and adolescents: a population-based epidemiological study.

The aim of the present study was to assess the distribution and characteristics of headache in children aged 7-14 years in Lower Saxony (Germany). For the survey, 8800 households with children were randomly drawn from community registers. Parents received comprehensive questionnaires regarding various aspects of their child's headache history and general health by mail. The response rate was 63.5%. The 6-month prevalence of paediatric headache was 53.2% and increased with age (39% at 7 years to 63% at age 14). Overall, recurrent headache (> or =1/week) was experienced by 6.5% of the total sample and was significantly more common among older girls (> or =11 years) than their male counterparts. Boys and girls did not differ markedly from one another regarding headache occurrence and frequency until the age of 11. Mean age of headache onset was 7.5 years, with onset occurring at a significantly younger age among boys than among girls. In accordance with International Classification of Headache Disorders-II criteria, migraine was diagnosed in 7.5% and tension-type headache in 18.5% of the cases, hence a large proportion of the children had unclassifiable headache. Of the headache disorders, migraine was rated the most disabling, with the highest average intensity, highest frequency, duration of headache often exceeding 2 h and more frequent use of medication. In general, aura symptoms were rare except for visual disturbances (17%). Paediatric headache was strongly associated with other health problems, including other pain symptoms. Paediatric headache was also associated with a history of parental headache.

Psychological treatment of recurrent headache in children and adolescents--a meta-analysis.

Psychologically based interventions such as relaxation training, biofeedback and cognitive-behavioural therapy are increasingly discussed as options for the treatment of migraine and tension-type headache in children and adolescents. In order to determine the state of evidence regarding the efficacy of these treatments, a meta-analysis of randomized controlled studies was conducted. In a comprehensive literature search including data from 1966 to 2004, 23 studies were found meeting the inclusion criteria. Due to the application of the random effects model, generalization of the results is possible. Specific statistical procedures were used to account for a possible publication bias. Significantly more patients improved to a clinically relevant extent (headache reduction > or =50%) in treatment conditions compared with waiting list conditions (high effect sizes). Long-term stability was also confirmed. The analysed treatments lead to improvement (up to 1 year) in headache status in children and adolescents with primary headache. However, more well-designed studies are needed to support and consolidate the conclusions of this meta-analysis and to compare the effects of psychological treatment with those of prophylactic medical interventions (in migraine), to examine potential differences between treatments, to identify moderators of efficacy and to determine effects of treatment on other health-related variables such as quality of life.

[Relaxation and biofeedback in the treatment of chronic headache in children and adolescents. A status report.]. / Relaxation und Biofeedback in der Behandlung von chronischem Kopfschmerz bei Kindern und Jugendlichen : Ein Uberblick.

The first studies on psychological treatment of pediatric headache appeared about 10 years ago; most of them were published in Anglo-American journals. This review focuses on relaxation training and biofeedback (EMG and hand temperature feedback) as the psychological interventions most often used in pediatric migraine and tension headaches. The results of randomized group studies, which were mostly well-controlled, on the efficacy of relaxation therapy (n=12) now allow a rather optimistic prognosis on the feasibility of this intervention. Most studies demonstrate clinically relevant reductions of headache frequency after training. Biofeedback studies are methodologically less well controlled and although positive effects have been observed, e.g., in single case studies, the relative usefulness of biofeedback has yet to be determined. Deficits in research on the psychological treatment of headache in children and adolescents are described, new research issues are discussed and recommendations for more systematic research are given.