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The Veterans RAND 12-Item Health Survey (VR-12) was added to the German Pain Questionnaire (DSF) as a self-report measure of health-related quality of life in 2016, replacing the previously used SF-12, which required a license. Both measures have 12 items and include a physical component summary (PCS) and a mental component summary (MCS). Evaluations with a larger sample on characteristic values and on the test-statistical goodness of the VR-12 in patients with chronic pain are so far missing. Data on the VR-12 and other procedures of the DSF were evaluated from 11,644 patients from 31 centers participating in KEDOQ pain. The patients filled out the DSF before starting a pain therapy treatment. Change sensitivity was determined for 565 patients for whom the VR-12 was available from a follow-up questionnaire of the DSF several months after the initial survey.The reliability (Cronbach's alpha) of the PCS was r tt  = 0.78 and for the MCS r tt  = 0.84. The MCS had significant relationships with the depression, anxiety and stress scales (r = -0.51 to r = -0.72), and the PCS correlated more highly with areas of pain-related impairment (r = -0.48 to r = -0.52). Patients with higher pain chronicity, those with higher pain severity, and those with evidence of high psychological distress described significantly lower health-related quality of life in PCS and MCS. The effect size (ES) of change in terms of improvement in health-related quality of life was ES = 0.33 in the MCS and ES = 0.51 in the PCS.The results are in agreement with the findings of the SF-36 and SF-12 in patient collectives with chronic pain. In summary, they show that the VR-12 is an adequate substitute for the SF-12 in the German pain questionnaire., (© 2021. The Author(s).)

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.

The direct comparison of day care pain patients with patients from other treatment sectors with respect to sociodemographic, pain-related and psychological characteristics has not yet been the subject of systematic analyses. The project core documentation and quality assurance in pain therapy (KEDOQ-pain) of the German Pain Society (Deutsche Schmerzgesellschaft e.V.) makes this comparison possible. This second analysis of the available KEDOQ data was intended to show how patients receiving day care treatment can be characterized using the core data set and whether and to what extent they differ from patients receiving outpatient or inpatient treatment. This is a continuation of the first publication, which showed remarkably small differences between outpatients and inpatients but did not include day care patients.The KEDOQ-pain data from 25 centers with a total of 8953 patients were evaluated. Patients had completed the German pain questionnaire (DSF) between January 2012 and March 2017 and received day care (n = 1264), outpatient (n = 4082) or inpatient (n = 3607) pain therapy treatment. Sociodemographic, pain-related and psychometric data of the DSF reported by patients were evaluated as well as physician information on the pain chronification stage and pain localization. The evaluation was descriptive and compared groups using univariate and multivariate procedures.Day care treated patients were significantly younger, had a higher level of education, were more frequently employed, reported higher impairment values and showed a higher severity index according to von Korff than inpatients and outpatients treated for pain. In addition, they described a shorter pain duration as well as worse habitual well-being (Marburg questionnaire on habitual well-being, MFHW). These predictors explained roughly half of the variance in the prediction of the day care treatment setting. The comparison of outpatients and inpatients showed significant group differences for some variables; however, the effects were very small.The evaluations suggest that pain therapy day care facilities treat a special group of pain patients that significantly differ from patients in other treatment sectors. Cautious conclusions are drawn regarding the systematic allocation of patients to care appropriate to their treatment needs.

Interdisciplinary multimodal pain therapy (IMST) is recognized as a scientifically founded form of therapy for inpatient treatment of chronic pain conditions. The indications are assessed by private practitioners and must be confirmed by physicians at the inpatient institution. The health insurance companies are obliged to remunerate this treatment but are allowed to test the conditions in individual cases. Recently, reports from members of the German Pain Society on a drastic increase in testing and rejection quotas have become more frequent. Therefore, this article discusses the legal foundations of the treatment of patients with chronic pain in the inpatient sector. Hard criteria for treatment in a certain sector could not be established. A decision in individual cases will depend on the complexity of the disease in the individual patient. A treatment in hospital is principally only necessary when the treatment corresponds to the generally recognized state of medical knowledge and treatment options in daycase units have not been successful. Important guidance can be found in the treatment guidelines of the medical specialist societies. The transfer to a more intensive treatment sector must be made dependent on the severity and complexity of the symptoms and the insufficient effectiveness of the treatment in the previous sector. Simple ICD-10 diagnoses are not suitable as decision-making criteria and therefore, also not as testing criteria for the indications for inpatient treatment. Decompensated and acutely exacerbated chronic pain conditions must as a rule be treated in hospital, also due to the mental component of the pain disease.

Based on the fundamental concept of the biopsychosocial model, interdisciplinary multimodal pain therapy (IMPT) has developed to one of the most important components in the treatment of patients suffering from chronic pain. The process criteria for IMPT in Germany are described in the German OPS catalogue and IMPT is mainly offered as an inpatient treatment only. This article updates some of the fundamental criteria for IMPT for adult inpatient treatment and the task force defines basic structural and process criteria for the implementation of IMPT for outpatients.

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.

With the implementation of the German diagnosis-related groups (DRG) reimbursement system in hospitals, interdisciplinary multimodal pain therapy was incorporated into the associated catalogue of procedures (OPS 8‑918). Yet, the presented criteria describing the procedure of interdisciplinary multimodal pain therapy are neither precise nor unambiguous. This has led to discrepancies in the interpretation regarding the handling of the procedure-making it difficult for medical services of health insurance companies to evaluate the accordance between the delivered therapy and the required criteria. Since the number of pain units has increased in recent years, the number of examinations by the medical service of health insurance companies has increased. This article, published by the ad hoc commission for interdisciplinary multimodal pain therapy of the German Pain Association, provides specific recommendations for correct implementation of interdisciplinary multimodal pain therapy in routine care. The aim is to achieve a maximum level of accordance between health care providers and the requirements of the medical examiners from health insurance companies. More extensive criteria regarding interdisciplinary multimodal pain treatment in an in-patient setting, especially for patients with chronic and complex pain, are obviously needed. Thus, the authors further discuss specific aspects towards further development of the OPS-code. However, the application of the OPS-code still leaves room regarding treatment intensity and process quality. Therefore, the delivery of pain management in sufficient quantity and quality still remains the responsibility of each health care provider.

In 2009 the diagnosis chronic pain disorder with somatic and psychological factors (F45.41) was integrated into the German version of the International Classification of Diseases, version 10 (ICD-10-GM). In 2010 Paul Nilges and Winfried Rief published operationalization criteria for this diagnosis. In the present publication the ad hoc commission on multimodal interdisciplinary pain therapy of the German Pain Society now presents a formula for a clear validation of these operationalization criteria of the ICD code F45.41.

A comparison of chronic pain patients in outpatient and inpatient treatment settings regarding pain-related and psychological characteristics, has not yet been systematically analyzed. The core documentation and quality assurance in pain therapy (KEDOQ-Schmerz) is a quality assurance system for documentation and quality management of pain therapy in different treatment settings. The system was initiated by the German Pain Society. We used KEDOQ-Schmerz data to describe differences between patients being treated in outpatient and inpatient settings with respect to social, pain-related and psychological factors. In total, the set of KEDOQ-Schmerz data analyzed included information from 4705 patients (from 13 clinics) collected between January 2012 and April 2016. Patients received either outpatient (n = 2682) or inpatient (n = 2023) treatment. The data analyzed comprised sociodemographic, pain-related and psychological data collected through the German Pain Questionnaire (DSF) at the beginning of treatment as well as information about pain chronification and pain localization provided by practitioners. The statistical analysis was carried out by descriptive and comparative data analysis using univariate and multivariate statistical methods. Patients with inpatient treatment were significantly older, more often female and more often had multiple pain localizations. They described stronger pain intensity and more frequently had a higher Mainz Pain Staging System (MPSS) score of pain chronification. They described a significantly poorer physical and mental health-related quality of life in the short form (SF-12) health survey, had significantly higher depression, anxiety and stress values (DASS) and a poorer habitual well-being in the Marburg questionnaire on habitual well-being (MFHW). Significant group differences had only small effect sizes. Even though most predictors for the inpatient treatment setting in multivariate analysis were significant, in total they explained less than 5% of the variance. The results indicate that pain therapy in specialized pain settings more and more has to manage patients with higher pain chronification, higher pain-related stress and previous therapy experience. The differences in patient characteristics between treatment settings are mostly clinically unimportant. Differences in clinical features do not declare the allocation to one treatment setting or the other.

On behalf of the Medical/Psychological Pain Associations, Pain Patients Alliance and the Professional Association of Pain Physicians and Psychologists, the Joint Commission of Professional Societies and Organizations for Quality in Pain Medicine, working in close collaboration with the respective presidents, has developed verifiable structural and process-related criteria for the classification of medical and psychological pain treatment facilities in Germany. Based on the established system of graded care in Germany and on existing qualifications, these criteria also argue for the introduction of a basic qualification in pain medicine. In addition to the first-ever comprehensive description of psychological pain facilities, the criteria presented can be used to classify five different levels of pain facilities, from basic pain management facilities, to specialized institutions, to the Centre for Interdisciplinary Pain Medicine. The recommendations offer binding and verifiable criteria for quality assurance in pain medicine and improved pain treatment.

Multimodal pain treatment programs are widely accepted as the medical treatment standard in the management of patients with chronic pain syndromes. The concepts and treatment strategies are based on the biopsychosocial model of pain and programs for early restoration of function. Although this concept is primarily implemented in the curative field, i.e. in hospitals for the treatment of patients with chronic pain diseases, modified programs based on the International Classification of Functioning (ICF) can now also be found in rehabilitation clinics. Despite the assumed similarities, significant differences in, for example the aims of the therapy and relevant structural and process variables have to be kept in mind when allocating patients to a program as provided by a hospital or a rehabilitation clinic. The aim of this article is to present the framework structures of both treatment levels with respect to the implementation of multimodal pain therapy programs and to elucidate the differential diagnostic approach to the indications.

Pain perception is a complex experience that entails somatic and psychological factors. This is especially true for chronic pain where increasing chronicity leads to a growing significance of psychological factors such as learning and memory processes or cognitive evaluation at the expense of nociceptive processes. Hardly any other area of health-related research and health care has such an interdisciplinary organization of research, treatment, and education. Psychological pain research and psychological treatment of pain have become specializations in their own right. For the future of this research area, a differential analysis of the contribution of psychological factors to chronicity is important. For a mechanism-oriented treatment, the development of new treatment approaches and the analysis of specific subgroups for a better differential indication of treatments is needed.

Multimodal pain management is a comprehensive treatment of complex chronic pain syndromes. In addition to medical therapy various other specialized therapeutic interventions based on the biopsychosocial model of pain origin and chronic pain development, are added. During the last few years treatment centers for chronic pain have been established throughout Germany. Multimodal pain management has been included in the official catalogue of the recognized medical procedures for day clinic units as well as for inpatient pain management. In daily practice there is, however, still a lack of clarity and of consistency about the components that multimodal pain management should contain. This is the reason for the ad hoc commission on multimodal interdisciplinary pain management of the German Pain Society to propose the following position paper that has been worked out in a multilevel and interdisciplinary consensus process. The paper describes the mandatory treatment measures in the four core disciplines of multimodal pain management, pain medicine, psychotherapy, exercise therapy including physiotherapy and assistant medical professions including nurses.

Background: Screening for risk factors for chronic low back pain (LBP) (yellow flags) is recommended by clinical guidelines. Various questionnaires to assess yellow flags have been proposed., Objectives: The aim of this study was to compare the prognostic validity of two screening questionnaires., Material and Methods: This was a prospective observational study with 241 LBP patients from 9 general practitioners, 4 orthopedic surgeons and 2 pain clinics. We compared the Örebro musculoskeletal pain questionnaire (ÖMSPQ) and the Heidelberg short questionnaire (HKF-R10) which were completed by all patients at inclusion before the consultation. Primary outcomes were assessed after 3 months by mail. Clinical endpoints were pain intensity, disability and more than two follow-up consultations., Results: The sensitivity of the HKF-R10 to predict the primary outcome ranged from 81 % to 88 %, while the specificity was much lower (37-47 %). The ÖMSPQ showed an opposite pattern with a low sensitivity ranging from 50 % to 58 % but a higher specificity (77-80 %). In patients initially classified as having chronic LBP (n = 81), using the questionnaires as a diagnostic tool, the sensitivity of both questionnaires increased but specificity decreased. Single items may perform better with regard to primary outcome than the sum scores., Conclusion: Both screening questionnaires for chronic LBP have insufficient diagnostic and prognostic validity for routine use in ambulatory care. Further studies are needed to improve diagnostic and prognostic validity and to elaborate criteria for a targeted use of screening questionnaires to guide therapeutic interventions.

Background: In recent decades, the focus of pain management in hospitals was the organization and quality of control of postoperative pain, although there is a similar demand in nonsurgical departments. The aim of this study was to assess the employees' perspective on problems and corresponding solutions in pain management in a university hospital and to further clarify whether the implementation of concepts and tools of pain management across disciplines is feasible., Methods: Physicians and nursing staff of all inpatient departments of the University Hospital Göttingen were asked about problems in pain management and the importance of various established instruments using a standardized questionnaire. Ratings were recorded on a numeric rating scale (0-10). The analysis was primarily descriptive, the Kruskal-Wallis and Mann-Whitney U test were used when appropriate., Results: In all, 149 medical and 501 nursing employees were included. The quality of pain management was perceived as better in surgical departments than in the conservative and pediatric departments. In all areas, the lack of an adequate order for baseline- and rescue-analgesic, and accordingly the nursing staff's limited ability to act was rated as problematic. In contrast to the conservative and pediatric departments, the predominant problem of surgical departments was the lack of availability of physicians on the ward. As a solution, the advice provided by pain consultation services was rated highly by the staff in all areas. The importance of implementation of standardized analgesic concepts was also supported equally in all areas. The evaluation of the quality of pain management was related to the employee's estimation of their ability to actively treat pain. Physicians rated problems in quality and organization lower compared to nursing stuff., Conclusion: The results demonstrate that from the employee's perspective problems in pain management in surgical and nonsurgical departments are very similar. Transferring concepts and structures of surgical pain management, such as standardized concepts and advice and or care through pain services, would meet high levels of acceptance. The results also indicate that the nursing staff's ability to treat should be increased by the provision of adequate rescue-analgesics. To close deficits in the management of care, established concepts of pain management could be extended to all departments of a hospital. Similarities outweigh differences in the employee's assessment.

According to evidence-based German national guidelines for non-specific low back pain, a broad multidisciplinary assessment is indicated after persisting pain experience of 6 weeks in order to check the indications for an multi- and interdisciplinary pain therapy program. In this paper the necessary topics, the content and the disciplines involved as well as the extent of the multidisciplinary assessment are described as developed by the ad hoc commission on multimodal pain therapy of the German Pain Society.

Background: The aim of this investigation was to describe the performance profile and the requirements for the management of complex pain patients for the structures of a consultation service., Material and Methods: The content and number of all inpatient consultations of the pain department (as an independent service in addition to acute pain and palliative care services) were evaluated for the period from 2008-2010., Results: During the study, 1,391 contacts were made in 882 patients; in approx. 50% of the consultations diagnostic or specific (interventional) procedures were requested. Beside additional diagnostic tests, physiotherapy (19.2%), psychological and psychiatric care (11.1%), and other therapeutic approaches (e.g., mirror therapy, transcutaneous electrical nerve stimulation, progressive muscle relaxation) or the long-term follow-up in specialized pain service (20.5%) were recommended., Conclusion: Within the scope of the pain consultation, a wide spectrum of pain diagnoses and difficult patients are examined. Mixed forms of acute, chronic, and tumor-related pain are often present. Therapeutically, optimization of only the pharmacological regimen is often not sufficient. Similar requirements for a multimodal diagnosis and therapeutic concept as established in ambulatory and/or specialist care are ultimately needed.

Multimodal therapy has demonstrated good clinical effectiveness in the treatment of chronic pain syndromes. However, within the German health system a comprehensive and nationwide access to multimodal therapy is not available and further improvement is therefore necessary. In order to analyze the current status of multimodal therapy and specifically its structural and procedural requirements and qualities, a survey was carried out in 37 pain clinics with established multimodal treatment programs. An anonymous questionnaire was used for data collection. Results demonstrated that a substantial accordance was found between all pain clinics concerning requirements for space, facilities and staff. Structured multidisciplinary assessments were carried out by all pain clinics even though the amount of time allocated for this varied widely. The main focus of multimodal therapy in all facilities was based on a common philosophy with a cognitive-behavioral approach to reduce patient helplessness and avoidance behavior and to increase physical and psychosocial activities as well as to strengthen self-efficacy. Some differences in the ways and means to achieve these goals could be demonstrated in the various programs.

KEDOQ-Schmerz was developed by the German Pain Society (formerly DGSS) as a basic tool for documentation and quality management of pain therapy. It is planned to use KEDOQ-Schmerz as the data basis for nationwide, cross-sectional and independent scientific research in health services in Germany. With comparatively little effort, each participating institution (practices, pain clinics) will be able to provide quality control of their own diagnostic procedures and therapeutic effects by using benchmarking. In future KEDOQ-Schmerz will also be used as a method for external quality management in pain therapy in Germany.

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.

Multimodal pain therapy describes an integrated multidisciplinary treatment in small groups with a closely coordinated therapeutical approach. Somatic and psychotherapeutic procedures cooperate with physical and psychological training programs. For chronic pain syndromes with complex somatic, psychological and social consequences, a therapeutic intensity of at least 100 hours is recommended. Under these conditions multimodal pain therapy has proven to be more effective than other kinds of treatment. If monodisciplinary and/or outpatient therapies fail, health insurance holders have a legitimate claim to this form of therapy.Medical indications are given for patients with chronic pain syndromes, but also if there is an elevated risk of chronic pain in the early stadium of the disease and aiming at delaying the process of chronification. Relative contraindications are a lack of motivation for behavioural change, severe mental disorders or psychopathologies and addiction problems. The availability of multimodal pain treatment centers in Germany is currently insufficient.

Objective: This study investigated the quality criteria of a screening procedure used to identify fear-avoidance beliefs., Methods: The translated version of the original FABQ was submitted to 302 patients with chronic back pain. Additionally, self-assessment protocols were used to document information on disease history, pain-specific parameters, extent of subjectively experienced impairment, and depressive symptoms., Results: Correlation statistical analysis confirmed the relevance of fear-avoidance beliefs for the impairment as experienced by the patients with back pain. The FABQ proved to be a better predictor of subjectively experienced impairment than pain intensity or affective/emotional orientation., Conclusions: Fear-avoidance beliefs represent significant cognitive factors for chronification of back pain. The results demonstrated the practicability, reliability, and validity of the questionnaire to assess fear-avoidance beliefs.

Background: The aim of our study was the analysis of the psychometric properties of the Ransford technique which is a qualitative scoring method of the pain drawing. It has been suggested that this method could be used as a brief screening technique for psychological involvement in pain complaints., Methods: 109 patients with chronic back pain filled in the pain drawing which was rated according to the technique described by Ransford and colleagues in 1976. As external criterium of validity we chose a differentiated expert rating of psychological interference., Results: The Ransford technique showed moderate to good coefficients of reliability (re-test, inter and intra-rater). On the other hand, the Ransford technique demonstrated very low indices of validity in order to give a prognosis about psychological interference. Sensitivity and specificity of the Ransford technique demonstrated inadequate values, which furthermore were independent from cut-off points., Conclusion: The pain drawing and the Ransford technique are not sufficiently sensitive and therefore allow no screening for psychological interference in complaints of back pain.

The German pain questionnaire (DSF) has been developed and validated by the Task force on "Standardization and Economy in Pain Management" of the German Chapter of the International Association for the Study of Pain (DGSS). The concept of the DSF is based on a bio (medical) - psycho - social pain model. The modular approach to pain assessment consists of:demographic data,pain variables (e. g. pain sites, temporal characteristics, duration, intensity),pain associated symptoms,affective and sensory qualities of pain (adjective list by Geissner, SESCopyright ),pain relieving and intensifying factors,previous pain treatment procedures,pain-related disability (Pain Disability Index by Tait et al.),depression test CES-D (Center for Epidemiological Studies Depression Test),comorbid conditions,social factors (educational level, occupation, retirement status, compensation and/or litigation status, disability for work),health related quality of life (SF-36Copyright ). Practicability and content validity were tested in some 3000 patients. Comparison with external criteria (e. g. medical and psychiatric-psychological diagnoses, physician-determined chronicity of pain) proved good content validity and excellent reliability of patients statements in the questionnaire. The great majority of patients stated that the DSF covered their pain history completely and in an orderly fashion. Difficulty to answer the questions was considered low. The German pain questionnaire is a reliable and valid instrument for recording the multidimensional experience of pain. Data from such questionnaires are indispensable for follow-up studies and internal and external quality assessments. The DSF can be ordered from the German Society for the Study of Pain (www.dgss.org) and is a core instrument of the computer program "quality assurance in pain management" (QUAST) of this society.

In the last 50 years conventional treatments have not been able to slow down the expanding chronic low back pain problem. However, nowadays health care has changed according to a broad biopsychosocial model of health, the positive effect of activity on health and healing, emphasis on function rather than pain or impairment, and reliance upon clinical evidence. In search for new solutions "functional restoration" (FR) programs have been developed. They include multidisciplinary treatment of patients in groups, consisting of 6-8 h of treatment a day, lasting 3 to 6 weeks and usually integrating intense physical and ergonomic training, psychological (behavioral) therapy, patient education, and instruction in social- and work-related issues. FR programs have yet to demonstrate their effectiveness in several countries. Controlled studies in the USA were very positive regarding the return-to-work rate, whereas studies in Scandinavian countries did not demonstrate similar results. Possible reasons for the different results concerning back-to-work ratios might be that study design, patient population, content of the program, and other external factors are different and studies as well as effects are therefore not directly comparable. According to several well-controlled studies, the most probable reason for this different effect may be that social and security (health care) systems and cultures differ among countries and that patients with chronic low back pain respond differently to this combination. Sick absenteeism and inability to work may be influenced by many factors besides pain that cannot be addressed by intervention or prevention programs, e.g., job satisfaction, education level, and the compensation systems. It may be that the lower economic benefit during sick leave in the United States leads to favorable results from functional restoration programs. Concerning the prediction of success, several studies have shown that medical background, diagnosis and physical impairment as well as physical variables (mobility, strength) have limited predictive value. Return to work and pain reduction are much better predicted by length of absence from work, application for pension, and the patients' disability in daily-life activities. In the last five years another important variable of success has been identified: avoidance behavior has been suspected to be a major contributor to the initiation and maintenance of chronic low back pain. The perpetuation of avoidance behavior beyond normal healing time subsequently leads to negative consequences such as "disuse syndrome", which is associated with physical deconditioning, sick role behavior, psychosocial withdrawal and negative affect. Accordingly, fear-avoidance beliefs were strongly related to absenteeism from work due to back pain and were the best predictors of therapy outcome in 300 acute low back pain patients. In a prospective study on 87 patients with chronic low back pain (CLBP) we demonstrated that fear-avoidance beliefs were the strongest predictors of return to work after a functional restoration treatment program. Although nonspecific mechanisms such as emotional disturbance, helplessness, pain anticipation, disability, and job circumstances could be identified as influencing the chronic pain process, we have to remember that long-lasting experience of pain is usually a very individual process in which several conditions may work together in a unique combination. Treatment procedures must consider this variability by focusing on general mechanisms, as well as on individual conditions and deficits. FR treatment strongly depends on behavioral principles that rule the whole therapeutic process: Adequate information is necessary to overcome unhelpful beliefs; information has to be related to the patients' daily experiences and their mental capability to understand them. Pacing, goal-setting, graded exposure with exercise quotas and permanent feedback as well as contingent motivation characterize the training procedures. Training procedures must incorporate the patients' daily activities early on. The patients' efficacy expectations are the most potent determinants of change in the training process. Exacerbation of pain is not taken as a failure of the therapeutic concept, but as a challenge to self-management. However, the important principle in managing chronic low back pain is "treating patients rather than spines."

Introduction: Chronic pain is an individually variable experience, incorporating physical, psychological and social dimensions. Chronic pain occurs in a broad spectrum of severity; therefore, a grading procedure is of crucial importance in clinical research and in epidemiologic studies. The Mainz Pain Staging System is an interview-administered, multi-dimensional measure of chronic pain severity. The system suggests grading chronic pain in terms of 4 axes: time (persistence), spreading of pain site, medication use, and health care utilization. The whole scale consist of 10 items. The resulting score is used to classify the pain problem in three stages (I, II, III). Analysing the broader validity and parametric properties of the staging system is the purpose of the present study., Methods: The staging system and psychosocial data were administered to 542 consecutive patients of different diagnoses who attended one of six pain clinics in the year 1995/96. In a time period of 3 months since first contact, treatment procedures were registered. Three months after first contact patients rated the effectiveness of treatment concerning reduction of pain intensity., Results: According to the criteria of the staging system 25% of the sample belonged to each stage I and stage III, whereas 50% were classified to stage II. As a measure of validity, chronic pain status demonstrated significant correlation with psychological impairment, disability and time off work, whereas there was no correlation to pain intensity and persistence of pain. Surprisingly we found no difference in amount and quality of treatment between patients who were graded as severe pain patients (stage III) and the other stages. Furthermore, effectiveness of treatment also did not differ between the three stages. We made several proposals for optimizing the staging system., Conclusion: Given the high prevalence of recurrent and chronic pain as well as the broadness of severity, an important issue on further research is identification of factors which influence the chronification process. For this purpose improved measures of graded classification of pain status are needed.

Introduction: In recent years most industrialized nations have been confronted with a dramatic increase in cases dealing with back pain which, because of the associated costs, has put a strain on health care systems. Because of the tremendous costs caused by patients with chronic illnesses, there is a common interest in identifying determinants responsible for the pain becoming chronic. According to the fear-avoidance model, chronic back pain is the cause of specific patient beliefs according to their perception and appraisal of back pain and their assumptions about the connection between pain and work activities. These fear-avoidance beliefs are assumed as the main cognitive factors of adapting to chronic invalidism. In this study a German version of a self-reporting instrument that assesses fear-avoidance beliefs (FABQ, Waddell et al. 1993) is presented., Methods: A translated version of the "Fear-Avoidance Beliefs Questionnaire" was given to 87 patients with back pain, who took part in a multimodal treatment program in an outpatient pain unit. The questionnaire was administered at different times in the therapeutic process. We examined the factor structure of the questionnaire and conducted the first examinations concerning its psychometric properties., Results: The results of our data set concerning different aspects of reliability and validity conform the good psychometric properties of the questionnaire. The factor analysis revealed a three-factor solution, which accounted for nearly 60% of the variance. The first factor made up 34% of the variance. The six corresponding items dealt with "back pain caused by work". The second factor made up 13% of the variance. The content of the 5 items is focused on the patients' view about his/her probable return to work. Beliefs about physical activity in back pain (factor 3, 5 items) accounted for 12% of the variance. Correlation analysis demonstrated that all three factors are of independent value, which showed satisfactory reliability. Furthermore, we analyzed the prognostic value of the three factor dimensions. Patients completed multidisciplinary treatment according to the concept of "functional restoration". At the end of treatment, factor 1 (causation by work) was not diminished, but both other factors showed significant reductions. In a discriminant factor analysis, back-to-work could be significantly predicted by factor 3 (beliefs about physical activity) and factor 2 (patients' prognosis about their probable return to work at the beginning of treatment). Furthermore, length of time off work and age accounted for an additive classification rate of 77%. The FABfactor 1 (causation by work) was of no predictive value., Conclusions: The results suggest that primary target points for further investigation include an analysis of the patients' beliefs about their pain, with special emphasis on fear-avoidance beliefs. It is also necessary to analyze the behavioral assumptions of the fear-avoidance model in an experimental design. Furthermore, our results concerning the psychometric properties of the questionnaire should be proved in a far larger sample of back pain patients.

Unlabelled: Pain perception is a complex psychosomatic phenomenon and is influenced by different psychological variables. Apart from their pain perception, chronic pain patients also suffer from different bodily complaints. The clinical significance of this finding is not yet clear. Bodily complaints in chronic pain patients may represent (a) a bodily expression of depressive symptoms, (b) a sign of chronicity, and (c) the expression of a heightened bodily awareness in the sense of hypochondriasis., Methods: A psychometric study was done with 83 patients with chronic low-back pain. The patients were interviewed and tested psychometrically. We administered a German scale to measure bodily complaints (BL), an inventory to measure the extent of depressive symptoms (DS) and two subscales of an personality inventory (bodily complaints and hypochondriasis). In addition, patients were evaluated according to three stages of chronification ("Mainz Pain Staging System"). Ten anamnestic variables from four dimensions (temporal aspects, spatial aspects, medication usage behavior and patient's health care history) are added to yield a total chronification stage with three stages ranging from acute to chronic pain., Results: Results indicate that bodily complaints have to be interpreted as signs of depressive disorder and chronicity. Signs of bodily 'awareness' or 'somatic anxiety'- in the sense of hypochondriasis - could not be found. Hypochondriasis does not seem to play a significant role in chronification of low back pain., Conclusions: From a cognitive-behavioral perspective the results support the hypothesis that psychological disturbance in chronic pain is a cause of long-standing pain perception and the result of the chronification process.

Problem: Studies using a multimodal approach in order to prognose therapeutic success in patients suffering from back pain were seen to have highly diverse results. However, in spite of various independent health care systems, a common interest prevails in identifying determinants of therapeutic success in order to improve therapy., Methods: Ninety disabled patients with chronic low back pain were admitted to an 8-week out-patient program of functional restoration and behavioral support. The program consisted of a pre-program (education, stretching and calisthenic exercises 4 h a day, three times a week for 3 weeks) and an intensive treatment period (physical exercises, back school education, cognitive behavioral group therapy, relaxation training, occupational therapy, socioeconomic and vocational counseling) which took place for 5 weeks, 7 h a day as an outpatient program. The program's philosophy encourages active effort on the patients' part in order to improve their functional status within a therapeutic environment. This reinforces behavior conducive to getting well, enhances the patients' sense of self-control over their pain and the resulting disability. The main therapeutic target was to facilitate the patients' return to work. Apart from medical examination and personal interview, the patients' physical impairment, pain descriptions, and psychological distress were also measured. This included variables such as depression, psychovegetative complaints, quality of life and workplace satisfaction, disability, and coping with disease. Measurements were repeated at the end of the 8-week program, and following 6 and 12 month intervals. The reliability of prognostic factors in predicting treatment outcome (return to work, reduction of pain intensity, self-assessment of success by the patients) was tested by analyses of variance and discriminant function analyses., Results: Patients' return to the workplace could be predicted in 85% of cases based on whether an application for pension had been made, on the length of duration of work disability, and on "fixed" assumptions on the part of the patient concerning his work situation. Pre-treatment somatic findings (for example, diagnosis, degree of physical impairment, and functional debilities), together with depressive and psychovegetative reactions, were shown to have no connection with the patient's ability to return to the workplace. Similar findings were demonstrated for the prediction of pain reduction and patient satisfaction with treatment., Conclusions: Predicting successful treatment is hardly possible without analyzing individual circumstances, focusing on sociodemographic variables, workplace-related conditions, and aspects of individual motivation. With regard to objective therapeutic success, subjective perceptions proved highly influential. Treatment proved successful only when the patient's perception of functional disability was minimized. Hence, individual perceptions and experiences were more important than physical capabilities.

Problem: The majority of authors agree today that psychosocial factors have more influence on a successful treatment of chronic back pain than other variables, in particular medical findings. Therefore treatments aim to integrate psychotherapeutic intervention in order to lessen emotional impairment, to change behavioral patterns (which advocate rest and the avoidance of physical activity), and to change cognitive attitudes and fears concerning exercise and work ability. Nevertheless, the interplay of cognitive measures and disability in treatment programs still remains an unclear issue., Methods: Ninety disabled patients with chronic low back pain were admitted to an 8-week outpatient program of functional restoration and behavioral support. The program consisted of a pre-program (education, stretching and calisthenic exercises) and an intensive treatment period (physical exercises, back school education, cognitive behavioral group therapy, relaxation training, occupational therapy, vocational counseling), which took place for 5 weeks, 7 h a day, as an outpatient program. The targets of the psychological interventions were (a) to change maladaptive behavior (inactivity, social withdrawal) and increase the patient's activity level at home, (b) to alter maladaptive cognitions (somatization, catastrophizing, passive expectations concerning treatment) and to improve their own positive coping skills, (c) to identify and stop operant conditioned behavior, and (d) to prevent depressive symptoms and strengthen the level of emotional control. The program's philosophy encouraged the patients' active efforts to improve their functional status within a therapeutic environment that reinforced positive behavior traits conductive to getting well. The main therapeutic target was to facilitate a return to work. Apart from a medical examination and a personal interview, the patients' physical impairment, pain descriptions, and psychological distress (according to different criteria for evaluation) were also measured. This included variables such as depression, psychovegetative complaints, quality of life and workplace satisfaction, disability, and coping with disease. Measurements were repeated at the end of the 8-week program, and following 6- and 12-month intervals., Results: In comparison with the initial values, a statistically significant improvement became evident in reducing pain, disability, depression, and psychovegetative signs (P < 0.001). Nearly all results remained stable at the 6- and 12-months examinations. Apart from these results, coping measurements demonstrated little improvement in the three factorial coping dimensions. By use of regression analyses, a differentiated description of psychosocial connections became apparent in three different ways of coping (catastrophizing, searching for information, cognitive control) and parameters of disability. Disability levels corresponded poorly with pain descriptions, physical impairment and coping dimensions. This result indicates that disability should be viewed as a separate component in assessing the patients' description of low back pain., Conclusion: An analysis of coping dimensions demonstrated that current cognitive measures might be too general to explain low back disability adequately. In addition, the results indicate that the use of the 'catastrophizing' factor as a separate variable is questionable, since it may simply be a symptom of depression. The relevance of coping as a sensitive parameter for change is also addressed. It is suggested that an alteration in coping strategies may be an important treatment effect, but is subject to individual prerequisites to maximize treatment response. Thus, future research must focus on the complex interactions between personality variables, environmental factors, and the coping demands posed by the specific nature of pain problems. A more lengthy evaluation of so-called 'fear-avoidance beliefs' in combination with 'disability' and coping dimensions could possibly lead to further treatment on the development of chronicity in chronic low back pain patients.

Problem: There is a great need to expand current knowledge of the various functional capacity measurements used in the rehabilitation of chronic low back pain (CLBP) patients. The literature on these patients reports that mobility, endurance, trunk strength and lifting capacity decrease during the process of chronicity. Chronically disabled patients appear to have lower functional capacity than asymptomatic persons., Methods: Our study group consisted of 90 disabled CLBP patients (44 female, 46 male; average age 42 years) who underwent a multidisciplinary 8-week daily treatment program of functional restoration with behavioral support (instruction, endurance training, strength exercises, behavioral and treatment to facilitate return to work therapy). Initially these patients where compared with 107 asymptomatic persons (44 female, 63 male, average age 41 years). The patients were investigated before and after treatment, and at intervals of 6 and 12 months. The reliability of the functional measurements was evaluated by interrater comparison. Physical assessment included a medical examination (mainly diagnosis of radicular or nonradicular pain), changes in the lumbar spine revealed by X-ray studies according to Herron and Turner, rating of physical impairment according to Waddell, flexibility, length of hamstrings muscles (SLR), test of power and endurance of trunk movement by standardized exercises according to the Swiss group of Spring and isokinetic measurements (LIDO Back), tests of lifting capacity (LIDO Lift), and (in part) of general endurance on a cycle ergometer (CASE 15 Marquette)., Results: Physical findings showed that mobility was reduced substantially in patients suffering from back pain due to reduced SLR (shortened hamstrings) and decreased spinal mobility. Patients also demonstrated significant reductions in their ability to perform lifting tasks in comparison to healthy individuals. The results of trunk flexion showed no significant differences between patients and the control group, whereas the ability to perform trunk extension was much better in the control group. In principle we found the same results with isokinetic measurements as in the exercises without machines. Cardiovascular endurance was also much better in the control group than it was in the back pain patients. At the end of the treatment program all physical deficits were improved significantly. In many cases performance was comparable with that of the control group. With time, however, training effects gradually decreased. The success of treatment (return to work, absence from work, pain reduction, use of medical care) was independent of the functional status of the patients before and after treatment., Conclusion: Study results showed that physical capacity in disabled patients with low back pain is substantially reduced in comparison to persons who do not suffer from back pain. The only exception was in trunk flexor strength and endurance, in which measurements did not differ between the patients and the control group. However, even CLBP- patients with long-term pain and severe physical illness can successfully improve their physical condition by participating in an active treatment program. Back extensor muscle training has to be included in physical therapy. Because of loss of condition during the time after treatment, regular monitoring of patients and their home training programs is necessary. Overall, treatment of CLBP has to include physical training and psychosocial treatment to achieve satisfactory results.

Unlabelled: A multimodal treatment program is presented in cases of functional restoration for chronic low back pain. The study comprises four parts. Part I gives an overview of the different results of the study. Part II focuses on the medical and functional examination in comparison with persons who do not suffer from back pain. Part III describes psychosocial aspects (depression, complaints, ways of coping, disability) and psychotherapy. In part IV prognostic factors and their reliability for predicting treatment outcome (return to work, pain intensity, self-assessment of success by patients) are examined. In addition the relevant effects of the program on social and health care systems are also addressed., Problem: The incidence of low back pain is continuously increasing, causing tremendous costs for the health insurance system. Therefore effective treatment methods are needed that take into account somatic, psychological and social factors. Chronic low back pain is conceptualized as a complex phenomenon including biological, social and psychological aspects, all of which should be addressed in a treatment program. A multimodal treatment program for chronic low back pain is presented, in which physical activity and cooperation of the patient are the primary targets. Therapeutic aims focus less on pain reduction and emphasize instead pain control, individual responsibility of the patient, and early reintegration into the working environment. The specific goals of the program are to increase the physical abilities of the patients (i. e., flexibility, strength and endurance), to increase patients' knowledge and the use of body mechanics and back protection techniques, to decrease medication-intake, to decrease dependency on the medical community, to improve patients' own positive coping skills and levels of emotional control, to increase the patient's activity level at home and to facilitate a return to work., Methods: A total of 90 disabled patients with chronic low back pain were admitted to an 8-week program of functional restoration and behavioral support. The program consisted of a pre-program (3 weeks: education, stretching and calisthenic exercises) and an intensive treatment period (aerobics, functional strength and endurance exercises, back exercises, cognitive behavioral group therapy, relaxation training, socioeconomic and vocational counseling) which took place for 5 weeks, 7 h a day, on an outpatient basis. Apart from a medical examination and a personal interview, the patients' physical impairment, pain descriptions, and psychological distress (according to different criteria for evaluation) were also measured. This includes variables such as depression, psychovegetative complaints, quality of life and workplace satisfaction, disability, and coping with disease. Measurements were repeated at the end of the 8-week program, and after 6 and 12 months., Results: In total 84 patients (94 %) were examined following treatment. There was a statistically significant improvement in flexibility, strength, lifting capacity, and endurance measurements ( p < 0.001) at the end of the treatment. In addition, significant reductions in pain, disability, depression, and psychovegetative signs were demonstrated ( p < 0.001). There was a decreased use of medical treatment for back pain following the program, with 42 % of the patients refraining from the intake of analgesics, followed by a significant reduction in physiotherapy and the consultation of physicians. Assessment of the patients' reported increased activity levels at home also supported findings that statistical improvements were significant. Sixty-three percent of the patients were found to have returned to active, productive work following discharge from the program. Most of the improvements remained stable at the 6- and 12-month follow-up examinations., Conclusion: The results demonstrate the effectiveness of the multimodal program of functional restoration, not only concerning positive changes in somatic, psychological and physical variables, but also with respect to the number of patients who returned to work. Our methods are also compared with the discrepant results of multimodal treatment in the United States and Scandinavia.

In pain clinics, thorough documentation of patient-related data is essential for analysis of patient history, long-term evaluation of diagnostic and therapeutic procedures, and research on the etiology and epidemiology of chronic pain syndromes. With these requirements in mind, we realized a microcomputer documentation system based on a commercial data-base software concept (dBASE). Each patient's data are stored in three different sections: data for identification, basic data (mainly diagnostic findings), and treatment related follow-up data. The program was initially developed to run on a single IBM/XT- or AT-compatible computer (at least 640 kB RAM, 1 hard-disk-drive) with MS-DOS but has now been improved to work on a local area network (LAN) with the NOVELL-Netware operating system. Important features of our new system are: multi-user capability, flexible data management via menu-driven user dialogue, rapid data access, and high compatibility allowing data exchange with other standard software packages. The microcomputer documentation system offers listings for administration as well as effective patient scheduling thanks to a recall system by date of last contact, selected therapeutic procedures and any other item in the medical record. A mail-merge service can be applied, which is particularly useful for follow-up-studies. The documentation system means routine work can be standardized and performed in an economical manner, with the ultimate aim of enhancing the quality of pain therapy.