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ZusammenfassungDer Veterans RAND 12-Item Health Survey (VR-12) wurde als Selbstbeurteilungsverfahren zur Erfassung gesundheitsbezogener Lebensqualität 2016 in den Deutschen Schmerzfragebogen (DSF) aufgenommen und ersetzt den bis dahin verwendeten lizenzpflichtigen SF-12. Beide Verfahren haben 12 Items und führen zu einer körperlichen und einer psychischen Summenskala. Auswertungen der deutschen Version mit größerer Stichprobe zu Kennwerten und zur teststatistischen Güte des VR-12 bei Patienten mit chronischem Schmerz fehlen bislang.Daten zum VR-12 und weiterer Verfahren des DSF wurden von 11.644 Patienten aus 31 an KEDOQ-Schmerz beteiligten Zentren ausgewertet. Die Patienten hatten den DSF vor Beginn einer angestrebten schmerztherapeutischen Behandlung ausgefüllt. Die Bestimmung der Änderungssensitivität erfolgte für 565 Patienten, für die der VR-12 aus einem Verlaufsfragebogen des DSF mehrere Monate nach der Ersterhebung vorlag.Die Reliabilität (Cronbachs Alpha) der körperlichen Summenskala war rtt = 0,78 und für die psychische Summenskala rtt = 0,84. Die psychische Summenskala wies deutliche Beziehungen zu den Depression-Angst-Stress-Skalen (DASS) auf (r = −0,51 bis r = −0,72), die körperliche Summenskala korrelierte höher mit Bereichen schmerzbedingter Beeinträchtigungen (r = −0,48 bis r = −0,52). Patienten mit höherer Schmerzchronifizierung, solche mit höherem Schmerz-Schweregrad und solche mit Hinweis auf hohe psychische Belastung beschrieben in beiden Summenskalen signifikant geringere gesundheitsbezogene Lebensqualität. Die Effektstärke (ES) der Veränderung im Sinne einer Verbesserung der gesundheitsbezogenen Lebensqualität war in der psychischen Summenskala ES = 0,33 und in der körperlichen Summenskala ES = 0,51.Die Ergebnisse sind in Übereinstimmung zu Befunden zum SF-36 bzw. SF-12 bei anderen Patientenkollektiven mit chronischem Schmerz. Sie zeigen zusammengefasst, dass mit dem VR-12 ein angemessener Ersatz zum SF-12 im Deutschen Schmerzfragebogen integriert wurde.

ZusammenfassungDie Versorgung von Patienten mit Schmerzen und Chronifizierungsrisiko ist nach wie vor gekennzeichnet durch Über‑, Fehl- und Unterversorgung. Das Projekt PAIN2020 (Innovationsfonds 01NVF17049) hat zum Ziel, durch die Einführung eines frühzeitigen, auf Schmerz spezialisierten interdisziplinären diagnostischen Ansatzes die ambulante Versorgung von Patienten im Hinblick auf Schmerzen und das Funktionsniveau zu verbessern. Im Rahmen einer randomisierten kontrollierten Studie werden bundesweit in 31 Einrichtungen der Regelversorgung (schmerzspezialisiertes Angebot) Patienten mit Risikofaktoren bei bestehenden Schmerzen einer frühen Schmerzdiagnostik zugeführt. Die Interventionsbedingung besteht dabei in einem interdisziplinären multimodalen Assessment mit den beteiligten Disziplinen Schmerzmedizin, Physiotherapie und Psychologie. Die Kontrollbedingung umfasst einen einmaligen Termin bei einem Schmerztherapeuten der Qualitätssicherungsvereinbarung Schmerzmedizin bzw. mit Zusatzbezeichnung spezielle Schmerztherapie. Patienten und Vorbehandler erhalten entsprechend der Befunde detaillierte Empfehlungen für eine weitere bedarfsgerechte Behandlung. Es sind 2 Evaluationsansätze geplant. Für den ersten beträgt die zu erreichende Nettofallzahl 3840 Patienten, deren klinische Daten (Deutscher Schmerzfragebogen, zusätzliche Skalen) längsschnittlich erhoben (Einschluss, 3 und 6 Monate nach Diagnostik) und auf Grundlage eines Mehr-Ebenen-Modells ausgewertet werden. Im Rahmen eines 2. Ansatzes werden diese klinischen Daten einerseits um Sekundärdaten der BARMER ergänzt sowie die Patienten des ersten Evaluationsansatzes mit BARMER-Versicherten gematcht, die an dem Projekt nicht teilgenommen haben. Die Auswertung übernimmt ein externes Evaluationsinstitut. Das Projekt startete im April 2018.

Der direkte Vergleich teilstationarer Schmerzpatienten mit Patienten anderer Behandlungssektoren hinsichtlich soziodemografischer, schmerzbezogener und psychischer Merkmale war bislang noch nicht Gegenstand systematischer Analysen. Durch das Projekt „KErnDOkumentation und Qualitatssicherung in der Schmerztherapie“ (KEDOQ-Schmerz) der Deutschen Schmerzgesellschaft wird dieser Vergleich moglich. Diese zweite Analyse der vorliegenden KEDOQ-Schmerz-Daten soll zeigen, wie sich teilstationar versorgte Patienten anhand des Kerndatensatzes charakterisieren lassen und ob und in welchem Ausmas sie sich von Patienten unterscheiden, die einer ambulanten oder stationaren Behandlung zugefuhrt werden. Es handelt sich um eine Fortsetzung der ersten Veroffentlichung, die bemerkenswert geringe Unterschiede zwischen ambulanten und stationar versorgten Patienten zeigte und bei der keine teilstationaren Patienten berucksichtigt wurden. KEDOQ-Schmerz-Daten aus 25 Zentren mit insgesamt 8953 Patienten wurden ausgewertet. Die Patienten hatten den Deutschen Schmerzfragebogen (DSF) zwischen Januar 2012 und Marz 2017 ausgefullt und erhielten ein teilstationares (n = 1264), ambulantes (n = 4082) oder stationares (n = 3607) schmerztherapeutisches Versorgungsangebot. Ausgewertet wurden soziodemografische, schmerzbezogene und psychometrische Daten der Patienten im DSF sowie Arztangaben zum Schmerzchronifizierungsstadium und zur Schmerzlokalisation. Die Auswertung erfolgte deskriptiv und gruppenvergleichend mit uni- und multivariaten Verfahren. Teilstationar behandelte Patienten waren signifikant junger, wiesen ein hoheres Bildungsniveau auf, waren haufiger berufstatig, berichteten hohere Beeintrachtigungswerte und zeigten einen hoheren Schweregradindex nach von Korff als ambulant und stationar versorgte Schmerzpatienten. Zudem beschrieben sie eine kurzere Schmerzdauer sowie schlechteres habituelles Wohlbefinden (MFHW). Durch diese Pradiktoren wurde etwa die Halfte der Varianz in der Vorhersage des teilstationaren Behandlungssettings erklart. Der Vergleich der ambulant und stationar behandelten Patienten zeigte fur einige Variablen signifikante Gruppenunterschiede, die Effekte hierbei waren allerdings sehr gering. Die Auswertungen sprechen dafur, dass in schmerztherapeutischen Tageskliniken eine besondere Gruppe von Schmerzpatienten behandelt wird, die sich von Patienten der anderen Behandlungssektoren deutlich unterscheidet. Es werden vorsichtige Schlussfolgerungen bezuglich der systematischen Allokation der Patienten zu der ihrem Behandlungsbedarf entsprechenden Versorgung gezogen.

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.

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.

Der Vergleich ambulant und stationar versorgter Schmerzpatienten hinsichtlich schmerzbezogener und psychischer Merkmale war bislang noch nicht Gegenstand systematischer Analysen. Die KErnDOkumentation und Qualitatssicherung in der Schmerztherapie (KEDOQ-Schmerz) ist ein von der Deutschen Schmerzgesellschaft initiiertes Projekt zur einheitlichen sektorenubergreifenden Dokumentation der in deutschen Schmerzeinrichtungen versorgten Patienten. Unsere Auswertung soll unter Verwendung von KEDOQ-Schmerz zeigen, in welchen sozialen, schmerzbezogenen und psychischen Merkmalen sich Patienten unterscheiden, die einer stationaren oder ambulanten Behandlung zugefuhrt werden, und wie ausgepragt die Unterschiede sind. KEDOQ-Schmerz-Daten aus 13 Zentren mit insgesamt 4705 Patienten wurden ausgewertet. Die Patienten hatten den Deutschen Schmerzfragebogen (DSF) zwischen Januar 2012 und April 2016 ausgefullt und erhielten ein ambulantes (n = 2682) oder stationares (n = 2023) schmerztherapeutisches Versorgungsangebot. Ausgewertet wurden soziodemografische, schmerzbezogene und psychometrische Daten des DSF (Fragebogen zur gesundheitsbezogenen Lebensqualitat: SF‑12; Depressions-Angst-Stress-Skalen: DASS; Marburger Fragebogen zum habituellen Wohlbefinden: MFHW) sowie Arztangaben zum Schmerzchronifizierungsstadium und zur Schmerzlokalisation. Die Auswertung erfolgte deskriptiv und gruppenvergleichend mit uni- und multivariaten Verfahren. Stationar behandelte Patienten waren signifikant alter, haufiger weiblich, hatten haufiger mehr als eine Schmerzlokalisation, berichteten starkere Schmerzen und hatten haufiger das Schmerzchronifizierungsstadium III im Mainzer Stadienmodell. Sie beschrieben eine signifikant schlechtere korperliche und psychische gesundheitsbezogene Lebensqualitat (SF-12), hatten im DASS signifikant hohere Depressions‑, Angst- und Stresswerte sowie ein schlechteres habituelles Wohlbefinden (MFHW). Die Auspragung der signifikanten Gruppenunterschiede war sehr gering. In der multivariaten Analyse zur Vorhersage des stationaren Behandlungssettings wurden die meisten klinischen Pradiktoren signifikant, durch sie wurden aber weniger als 5 % der Varianz aufgeklart. Die Auswertungen sprechen dafur, dass in schmerztherapeutischen Einrichtungen verstarkt Patienten mit hoher Schmerzchronifizierung und hoher schmerzbedingter Belastung und Therapievorerfahrungen behandelt werden. Die Unterschiede der Patientenmerkmale zwischen den Behandlungssettings sind grostenteils klinisch bedeutungslos. Klinische Merkmale erklaren nicht die Zuordnung zu einem ambulanten oder stationaren Behandlungssetting.

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

Keeping the unsatisfactory options for classifying chronic pain in mind, the “Multiaxial Classification of Pain – Psychosocial Dimension” (Klinger et al. 1992, 1998) offers an important, integrative approach to the nuanced codification system for pain diagnoses. By combining the MACPainP with the ICD-10 GM diagnosis F45.41 and the corresponding somatic ICD-10 diagnoses, it is now possible to describe the psychological factors of pain syndromes in a more nuanced fashion.

Im Abschnitt „Medikamentose Strategie“ des veroffentlichten Beitrags kam es zu einem Umrechnungsfehler. Bitte beachten Sie den korrigierten Text: Es liegt gute Evidenz dafur vor, dass – insbesondere beim opioidgewohnten Patienten – intraoperativ die Gabe von niedrigdosiertem Ketamin (0,5 mg/kgKG in

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

KEDOQ-Pain is a quality assurance system for documentation and quality management of pain therapy under different treatment settings initiated by the German Pain Society. We used KEDOQ-Pain data to describe initial differences in sociodemographic, pain-related and psychological factors between pain patients receiving pain therapy in inpatient or outpatient treatment settings. Our data, collected by the German Pain Questionnaire (DSF), comprised information on pain patients receiving out- and inpatient therapy (n=4,705). Statistical analysis was carried out by descriptive and comparative data analysis using uni- and multivariate statistical methods. Patients receiving inpatient pain therapy were significantly older, more often female and had more often multiple pain localizations. They reported greater pain intensity, had a higher stage of pain chronification and higher pain-related disabilities. They showed higher levels of anxiety, depression and stress and had a lower quality of life. Significant group differences, however, had only small effect sizes. Even though multivariate analysis revealed most predictors of treatment in an inpatient setting to be significant, taken as a whole they explained less than 5% of the observed variance. Criteria underlying the current practice of allocation of patients to inpatient or outpatient pain therapy remain unclear. Our analysis suggests that highly chronified pain will increasingly be the challenge of future pain management, requiring professional competence from a multidisciplinary specialist team.

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

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

Erratum zu: Schmerz 2019 https://doi.org/10.1007/s00482-019-00400-9 Im ursprunglichen Artikel wurde die Zugehorigkeit der Autoren zu einer Kommission redundant dargestellt. Sowohl in der Online- als auch der Printversion des Beitrags wurde der Fehler behoben. Wir bitten Sie, den Fehler zu …

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 Gottingen 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.

Ziel dieser Untersuchung ist es, die Pravalenz und Bedeutung vorbestehender Schmerzen bei Patienten im Rahmen der postoperativen Versorgung durch den Akutschmerzdienst (ASD) darzustellen. Des Weiteren wird diskutiert, inwieweit sich durch diese Komorbiditat in der Praxis unmittelbare Unterschiede im Versorgungsaufwand, im Leistungsspektrum und in der Versorgungsqualitat des ASD ergeben. Es wurde eine inhaltliche und quantitative Auswertung aller ASD-Visiten innerhalb eines Zeitraums von 8 Wochen durchgefuhrt. Die Auswertung erfasste auch eine Qualitatsbeurteilung aus Patientensicht, die mithilfe des Patientenfragebogens aus dem Projekt Qualitatsverbesserung in der postoperativen Schmerztherapie (QUIPS) ermittelt wurde. Die Daten von 633 ASD-Visiten bei 128 Patienten wurden ausgewertet. Von diesen Patienten wurden 91 % wegen eines operativen Eingriffs aufgenommen (66 % Tumorchirurgie, 8 % Endoprothetik, 9 % sonstige Gelenkeingriffe, 17 % sonstige Eingriffe). Es hatten 50 % aller betreuten Patienten bereits mindestens seit 12 Wochen vorbestehende Schmerzen. Hiervon wurden 31 % als chronische Schmerzen (nichttumorbedingt) und 19 % als Schmerzen, die vermutlich im Zusammenhang mit der Tumorerkrankung standen, bewertet. Fur die Patienten mit vorbestehenden Schmerzen ergaben sich keine nennenswerten Unterschiede im direkten Betreuungsaufwand und in der Qualitat der Versorgung, abgesehen von einer ofter nachfolgenden schmerz- und palliativmedizinischen konsiliarischen Betreuung. Vorbestehende Schmerzen sind eine haufige Komorbiditat bei operativen Patienten. Die Daten zur Ergebnisqualitat zeigen, dass diese Patienten von speziellen Verfahren und der Betreuung durch den ASD profitieren konnten. Im Gegensatz zu Studien zur allgemeinen postoperativen Schmerzbehandlung wiesen die vom ASD betreuten Patienten mit vorbestehenden Schmerzen keine hohere postoperative Schmerzintensitat auf, sodass vorbestehende Schmerzen eine sinnvolle Indikation zur Mitbetreuung durch den ASD sein konnten.

Nach den Empfehlungen der Nationalen VersorgungsLeitlinie »Kreuzschmerz« sollte bei 6-wochiger Schmerzdauer trotz leitliniengerechter Therapie bei positivem Nachweis von Risikofaktoren zur Chronifizierung ein umfassendes interdisziplinares Assessment stattfinden, um die Indikation zu einem multimodalen Therapieprogramm zu prufen. In diesem Beitrag werden die notwendigen Themenbereiche, die Inhalte und die beteiligten Disziplinen sowie der Umfang eines interdisziplinaren schmerztherapeutischen Assessments beschrieben, die von der Ad-hoc-Kommission »Multimodale interdisziplinare Schmerztherapie« der Deutschen Schmerzgesellschaft e. V. erarbeitet wurden.

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

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.

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

Bei korperlich belastenden Aktivitaten impliziert das Angst-Vermeidungs-Modell bei Patienten mit Ruckenschmerzen eine Uberschatzung der Anforderung bei gleichzeitiger Unterschatzung der eigenen Fahigkeiten. An 71 Patienten mit Ruckenschmerzen und 48 ruckengesunden Kontrollpersonen wurde die Ubereinstimmung der Selbsteinschatzung mit der tatsachlich erbrachten Leistung bei der Bewaltigung einer Hebeaufgabe uberpruft. Die Selbsteinschatzung und die tatsachliche Leistung weisen bei der Mehrheit der Ruckenpatienten wie auch der Ruckengesunden eine hohe Ubereinstimmung auf, wobei Patienten eine noch bessere Ubereinstimmung zeigen. Ruckengesunde zeigen in >35% der Falle eine Unterschatzung ihrer Hebeleistung, was bei den Patienten nur in 14% der Falle zutrifft. Ruckenpatienten zeigen dabei mit 14% der Falle deutlich mehr Uberschatzungen als Ruckengesunde (2%). Bei Patienten lassen sich subgruppenspezifische Unterschiede zwischen einer generell unter- und einer generell uberschatzenden Gruppe finden. Bei der Abgrenzung beider Gruppen spielen Schmerzintensitat, Angst-Vermeidungs-Uberzeugungen und die Anstrengungsbereitschaft eine wesentliche Rolle. Als Erklarung fur die z. T. unerwarteten Ergebnisse ist zu vermuten, dass es bei Patienten mit Ruckenschmerzen zu einer Aufmerksamkeitslenkung auf ruckenschmerzrelevante Inhalte wie das Heben kommt, sodass sie ihre Hebefahigkeit realistischer einschatzen konnen.

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.

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

Epidemiologic surveys frequently show that women more often and are more affected by low back pain (LBP). The aim of this secondary analysis of a randomized controlled study was to explore whether presentation and course of LBP of women is different from men, and if sex affects the use of healthcare services for LBP.Data from 1342 [778 (58%) women] patients presenting with LBP in 116 general practices were collected. Patients completed standardized questionnaires before and after consultation and were contacted by phone 4 weeks, 6 months, and 12 months later for standardized interviews by study nurses. Functional capacity was assessed with Hannover Functional Ability Questionnaire (HFAQ). Logistic regression models-adjusting for sociodemographic and disease-related data-were conducted to investigate the effect of sex for the use of healthcare services.Women had on average a lower functional capacity at baseline and after 12 months. They were more likely to have recurrent or chronic LBP and to have a positive depression score. Being female was associated with a low functional capacity after 12 months (odds ratio: 1.7, 95% confidence interval: 1.2-2.3), but baseline functional capacity, chronicity, and depression were stronger predictors. In univariate analysis, women had a tendency of higher use of healthcare services. Those differences disappeared after adjustment.Our findings confirm that women are more severely affected by LBP and have a worse prognosis. Utilization of healthcare services cannot be fully explained by female sex, but rather by a higher impairment by back pain and pain in other parts of the body characteristic of the female population.

Study design Cluster randomized controlled trial. Objective To improve quality of care for patients with low back pain (LBP) a multifaceted general practitioner education alone and in combination with motivational counseling by practice nurses has been implemented in German general practices. We studied effects on functional capacity (main outcome), days in pain, physical activity, quality of life, or days of sick leave (secondary outcomes) compared with no intervention. Summary of background data International research has lead to the development of the German LBP guideline for general practitioners. However, there is still doubt about the most effective implementation strategy. Although effects on process of care have been observed frequently, changes in patient outcomes are rarely seen. Methods We recruited 1378 patients with LBP in 118 general practices, which were randomized to 1 of 3 study arms: a multifaceted guideline implementation (GI), GI plus training of practice nurses in motivational counseling (MC), and the postal dissemination of the guideline (controls, C). Data were collected (questionnaires and patient interviews) at baseline and after 6 and 12 months. Multilevel mixed effects modeling was used to adjust for clustering of data and potential confounders. Results After 6 months, functional capacity was higher in the intervention groups with a cluster adjusted mean difference of 3.650 between the MC group and controls (95% CI = 0.320-6.979, P = 0.032) and 2.652 between the GI group and controls (95% CI = -0.704 to 6.007, P = 0.120). Intervention effects were more pronounced regarding days in pain per year with an average reduction of 16 (GI) to 17 days (MC) after 6 months (12 and 9 days after 12 months) compared with controls. Conclusion Active implementation of the German LBP guideline results in slightly better outcomes during 6 months follow-up than its postal dissemination. Results are more distinct when practice nurses are trained in motivational counseling.

Zusammenfassung. Ziel der Arbeit war die Untersuchung der Rolle von Depression und Bewegungsangst-Kognitionen (“fear-avoidance beliefs”) für die Bereitschaft zur Aufnahme und zur Beibehaltung körperlicher Aktivität bei Patienten mit Rückenschmerz. In die Sekundäranalyse einer randomisierten, kontrollierten Interventionsstudie gingen Daten von N = 1378 Patienten mit vorwiegend akuten Rückenschmerzen ein (58 % weiblich, mittleres Alter 49 Jahre). Personen mit hoher Depressivität und gleichzeitig starken “fear-avoidance beliefs” zeigten den niedrigsten Aktivitätsumsatz zur Baseline (kcal/Woche). Bedeutsamster Prädiktor für den Aktivitätsumsatz nach sechs bzw. 12 Monaten war neben der Baseline-Aktivität eine hohe Selbstwirksamkeitserwartung zur Baseline; Rückfälle in Inaktivität wurden v.a. durch geringe Selbstwirksamkeit und geringe wahrgenommene Vorteile von Bewegung vorhergesagt. Weder Depressivität noch Bewegungsangst erwiesen sich als bedeutsame Prädiktoren für körperliche Aktivität bzw. Rückfall in Inaktivität nach sechs bzw. 12 Monaten. Vergleichsweise stabile Konstrukte wie Depressivität oder Bewegungsangst-Kognitionen sind offenbar wenig geeignet, die Bereitschaft zur Aktivität oder tatsächliche Aktivität vorherzusagen. Es wird angeregt, verstärkt die Bedeutung von kognitiven und affektiven Aspekten situativer Entscheidungsprozesse für die Ausübung körperlicher Aktivität zu thematisieren.

Bei chronischen Schmerzen hat sich die aufeinander abgestimmte Anwendung von Behandlungsmethoden aus verschiedenen Fachdisziplinen bewahrt. Gleichwohl ist unter einer solchen multimodalen Herangehensweise nicht zu verstehen, dass verschiedene Methoden wahllos kombiniert werden. Auch die Durchfuhrung einer multimodalen Therapie sollte sich an theoretisch begrundeten und bewahrten Konzepten orientieren. Diese Konzepte lassen sich am Beispiel des Ruckenschmerzes gut darstellen. Das elaborierteste Modell zur Erklarung des Uberganges von akuten zu chronifizierten Schmerzen ist das Angst-Vermeidungs-Modell („fear avoidance“). Dabei wird der bei vielen Patienten zu beobachtende komplexe chronifizierte Status als eine gelernte Konsequenz verstanden, die sich aus der angstmotivierten Vermeidung von Bewegung und Belastung ergibt. Zielpunkt des sich daraus ergebenden Vorgehens ist nicht vorrangig die Behandlung einer korperlichen Pathologie, sondern die Wiederherstellung der Funktionsfahigkeit der Betroffenen („functional restoration“). Derartige Programme haben ihre Effektivitat inzwischen eindrucksvoll bewiesen. Die Effektivitat ist jedoch entscheidend von den notwendigen Inhalten der Behandlung sowie der Einhaltung wichtiger Behandlungsprinzipien abhangig (Vermeidung negativer Erwartungseffekte, verstarkter Einsatz „versichernder“ Techniken, kein Training genereller Belastungsvermeidung, Durchfuhrung der Behandlung nach Prinzipien der Angsttherapie).

In der vorliegenden Arbeit wurde die Effektivitat eines aktivierenden Behandlungsansatzes in der Therapie von chronischen HWS-Storungen an einer Gruppe von 40 konsekutiven Patienten in einem Pilotprojekt untersucht. Das standardisierte und in Kleingruppen von 2–4 Patienten durchgefuhrte Behandlungsprogramm umfasste 10 1-stundige Ubungseinheiten, in denen neben der Vermittlung von Informationen ein korperliches, funktionell orientiertes Ubungsprogramm durchgefuhrt wurde. Wahrend der Behandlung wurde fur jeden Patienten ein standardisiertes Heimubungsprogramm mit individuellen Schwerpunkten erarbeitet. Das Ziel dieser Konzeption bestand zum einen darin, Selbsthilfemasnahmen fur Beschwerden im Schulter-Nacken-Bereich zu erlernen und andererseits die bestehenden Fehlfunktionen auszugleichen sowie das Gelernte in den Alltag zu integrieren. Bei den berucksichtigten Patienten handelt es sich um typische Patienten mit chronifizierten HWS-Schmerzen. Sie hatten im Durchschnitt eine relativ hohe Schmerzintensitat von NRS 6, waren mittel bis stark beeintrachtigt und hatten im Bereich der Angst- und Vermeidungseinstellungen ebenfalls hohe Werte. Die Ergebnisse unserer Vorgehensweise zeigen eine gute Effektivitat des gewahlten Vorgehens insbesondere im Bereich des subjektiven Erlebens. Schmerzintensitat, affektiv-emotionales Schmerzerleben, Beeintrachtigungserleben und schmerz- und bewegungsbezogene Angste reduzierten sich nach der Behandlung in signifikantem Ausmas. Dabei zeigte sich, dass die subjektive Schmerzintensitat die groste Verbesserung erfahren hat. Die guten Ergebnisse dieses Vorgehens zeigen, dass schon mit sehr wenig therapeutischem Aufwand gute Effekte erzielt werden konnen, indem wir Patienten die Verantwortung fur ihre Gesundheit ubertragen.

Context:Trunk flexion and extension in normal participants using the Biodex and a LIDO-Back isokinetic trunk dynamometer.Objective:Assessment of interreproducibility of the isokinetic LIDO-Back system.Design and Setting:Intertester reproducibility study in a tertiary-care center (outpatient rehabilitation).Participants:10 healthy individuals (4 women and 6 men) with a mean age of 29 years.Main Outcome Measures:Intertester reproducibility correlations of the isokinetic LIDO-Back. Measurements of 2 therapists were calculated using intraclass correlation coefficient (ICC1,1).Results:For the flexion parameters the ICCs were between .86 and .98, and for extension, between .63 and .78.Conclusions:A high intertester reproducibility relating to measurements of the LIDO-Back isokinetic trunk dynamometer was demonstrated. Intertester-reproducibility studies should become a routine method in the rehabilitation process.

In der vorliegenden Arbeit wurden die Gutekriterien eines qualitativen Auswertungsverfahrens (Ransford-Bewertung) fur die Schmerzzeichnung untersucht. Bei 109 Patienten mit chronischen Ruckenschmerzen wurde die Schmerzzeichung nach dem Ransford-Bewertungsschema ausgewertet und weitere Daten der Krankheitsgeschichte sowie psychometrischer Testverfahren erhoben. Als externes Kriterium wurde ein Expertenurteil gewahlt, das die Ergebnisse aus 3 psychometrischen Testverfahren und den Ergebnissen der Exploration zu einem Wert integrierte. Das Verfahren weist eine relativ hohe Auswertungsobjektivitat und eine gute Wiederholungszuverlassigkeit (Retest-Reliabilitat) auf. Es ergaben sich jedoch niedrige Werte fur die Entscheidungsgute (Validitat) in Bezug auf die Vorhersage psychischer Auffalligkeit. Unabhangig davon, ab welchem Punktwert die Entscheidung fur eine auffallige vs. unauffallige Schmerzzeichnung getroffen wurde, waren die Werte fur Sensitivitat und Spezifitat (fur psychische Auffalligkeit) schlecht. Obwohl die Nutzlichkeit der Schmerzzeichnung fur die Dokumentation der Schmerzlokalisation und -ausbreitung unbestritten bleibt, ist sie als Diagnoseinstrument zur Erfassung einer psychischen Konfundierung bei Schmerzpatienten nicht geeignet.

OBJECTIVES AND METHODS In a cognitive framework appraisal and coping are seen as major factors in the adaptation of chronic pain patients. This study evaluates the differences between rheumatoid arthritis (N = 70) and fibromyalgia (N = 74) outpatients in regard to coping and appraisal, and the relationship between appraisal, coping and adaptation in general. RESULTS In rheumatoid arthritis patients acceptance of illness and cognitive-reappraising coping prevails. In fibromyalgia patients, however, passive, emotion-focused coping and the judgement of illness as a "threat" or "punishment" (Lipowsky) was pronounced. A connection between individual appraisal of the illness and means of coping was observed. There was also a strong relationship between coping and adaptation, with one third of the variance of the mood variables explained by appraisal and coping. The presence of a psychic disorders played only a minor role. CONCLUSIONS A detailed understanding of the relationship between appraisal, coping, and adaptation may contribute to improved treatment concepts in pain patients. One aim of psychotherapy in chronic pain patients should be to reduce passive, emotion-focused coping and to change maladaptative concepts of illness.

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.

Individuals with low back pain (LBP) present with alterations or limitations of spinal mobility. The identification of simple clinical methods for evaluating functional movement of the spine is necessary to allow quantification of the degree of movement impairment and permit monitoring of patient improvement with rehabilitation. This study evaluated movement of the spine in 20 patients with chronic nonspecific LBP compared with 19 pain-free participants using a novel measurement device that permits the dynamic assessment of spinal movement in a rapid and subject-specific manner.Two flexible sensor strips were fixed paravertebrally to the spine with each sensor strip measuring angles in 12 predetermined, adjacent, 25-mm-long segments. Maximum range of motion (ROM) and average angular velocity (AAV) of lumbar and pelvic movement were measured within identical angular and temporal frames during the descending and ascending phase of active lumbar flexion, extension, rotation, and lateral flexion following a standard choreography. Participants with LBP completed a number of questionnaires including the Tampa Scale of Kinesiophobia, Pain Catastrophizing Scale, and Spielberger State-Trait Anxiety Inventory.Across all movements, the individuals with LBP displayed 10% to 15% less ROM (P0.05) and 15% to 30% less AAV (P0.05) at both the pelvis and lumbar regions compared with controls. ROM as well as AAV, in most cases, were negatively correlated (R=-0.49 to -0.75) with the Tampa Scale of Kinesiophobia, Pain Catastrophizing Scale, and Spielberger State-Trait Anxiety Inventory in the LBP group (all P0.05) especially during the initial descending phase of movement.This study provide support for the utility of this device for quantifying movement impairments in individuals with fairly low levels of LBP and general functional limitations. The results show that velocity measurements rather than ROM show the greatest differences in individuals with LBP compared with asymptomatic participants. Impaired lumbar and pelvis movement was correlated to the individuals with LBP's degree of anxiety, fear, and catastrophizing.

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."

Reatment of Chronic Low Back Pain Through Intensive Activation - An Assessment of 10 Years. Aim of the study: Treatment of chronic low back pain is a difficult problem and usually of low effectiveness. Aim of the study was to analyse the effectiveness of a multimodal treatment procedure. Methods: From the basis of functional restoration concepts primarily established in the USA we conceptualized a treatment program which initially was funded by the German ministry of research. Over the years the regimen was modified in several respects (programs of different intensity). From 1990 to 2000 762 patients were treated in this way with one-year follow-up examination. Results: Patients who were off work had significant differences in psychosocial and pain-related variables in comparison to those patients who were still working. Treatment procedures were in general very effective, although a modification of the program with less treatment (no work-hardening) failed in repeating the same effects. Pain intensity, disability, amount of depression and psychological distress improved significantly as well as work capability and use of the health care system. Nearly all results were seen to stabilize at the 12-month evaluation. Discussion: Functional restoration programs for treatment of chronic low back pain have demonstrated effectiveness in several countries. By early use of these programs the high amount of costs due to back pain disability may be consequently reduced. Up to now in Germany these concepts are not wellknown and insurance companies as well as the health system do not yet acknowledge them.

Hintergrund: Die Beschreibung von Schmerzsyndromen ist durch eine Diagnose allein nicht ausreichend gewahrleistet; erst die Angabe der Krankheitsschwere ermoglicht sowohl die Indikation der entsprechenden Behandlung als auch eine Vergleichbarkeit von Fallen. Patienten und Methode: In einer multizentrischen Studie wurde bei 542 Patienten das aus der Mainzer Arbeitsgruppe um Gerbershagen 1986 vorgestellte Stadienmodell der Chronifizierung ermittelt und in Abhangigkeit von Patienten- und Diagnosemerkmalen sowie im Hinblick auf seine parametrischen Eigenschaften analysiert. Ergebnisse und Diskussionen: Die Ergebnisse der Untersuchung bestatigen die gute Validitat des Verfahrens im Hinblick auf seine Unabhangigkeit von schmerzspezifischen Parametern. Es besteht theoriegemas eine gute Ubereinstimmung zum Ausmas der emotionalen Befindlichkeit (Depression), zur subjektiven Beeintrachtigung und zum Ausmas der Arbeitsunfahigkeit. Die Ergebnisse zeigen auch Ansatze fur Verbesserungsmoglichkeiten. Einige der berucksichtigten Kriterien sind vermutlich uberflussig, wahrend der zusatzliche Einbezug des subjektiven Beeintrachtigungserlebens notwendig erscheint. Ob ein ubergreifendes Graduierungsmodell fur verschiedene Schmerzerkrankungen uberhaupt valide sein kann, muss eine weitergehende Analyse zeigen.