Contextual factors in persistent severe back pain: A longitudinal analysis among German employees

BACKGROUND

Chronic back pain in employees compromises participation in social and daily activities, as well as work.

OBJECTIVES

To examine the severity of back pain after 2 years and identify factors predicting stagnation at this level of pain.

METHODS

Data were derived from a prospective cohort study with randomized sampling of insurants in the German Pension Insurance using a questionnaire at baseline and follow-up after 2 years. The sample consisted of middle-aged employees (45-59 years) with strong limitations due to back pain (Chronic Pain Grade III or IV), who had not applied for disability pension and did not use medical rehabilitation in the previous 4 years before baseline. Stepwise multivariable logistic regression models with backwards selection were used to identify relevant contextual factors in the stagnation of severe back pain.

RESULTS

Of 1208 persons with severe back pain at baseline, 48% had stagnated at that pain level after 2 years. Predictors of persistent severe back pain were older age, poorer general health, more additional disabling conditions, more depressive symptoms, caregiving burden, less pain-related self-efficacy and more fear avoidance beliefs.

CONCLUSIONS

In a high-risk subgroup with several co-existing conditions, this analysis highlights (mental) health, social and personal (contextual) factors associated with long-term unfavourable back pain progression.

SIGNIFICANCE

Back pain is a condition that often has a chronic or recurrent course, threatening participation in many areas of life. In this study it was found that the unfavourable condition of severe back pain can remain stable for long periods of time in a significant proportion of sufferers. Contextual factors (self-efficacy, fear-avoidance beliefs, caregiving burden) as well as additional health problems should be considered when identifying persons with stagnating pain courses.

[Experts' uncertainties in decisions on the indication for rehabilitation as part of the assessment of long-term care needs: Results of semi-structured interview]

OBJECTIVE

As part of assessment of long-term care needs, Medical Services of the compulsory German Health Insurance have to decide whether medical rehabilitation is indicated. The aim of this study was to identify uncertainties and associated factors while deciding whether rehabilitation was indicated in this standardized review process.

METHOD

Semi-structured interviews were conducted with a total of twelve nursing experts and six physician experts from six different Medical Services. In the interviews of the two professional groups, thinking aloud and problem-centered methods were used. They were subjected to a cognitive pretest prior to data collection. All interviews were conducted over telephone in May 2021, digitally recorded and transcribed thereafter. They were analyzed based on the method of structuring qualitative content analysis using the MAXQDA software.

RESULTS

Uncertainties in decision-making can arise both from case-related characteristics and case-independent contextual factors. Nursing experts associated uncertainties in assessing the criteria of rehabilitation indication primarily with certain diseases (especially dementia or mental illnesses), multimorbidity, an unclear illness and ambulatory care situation, as well as a negative rehabilitation-related attitude of the persons being assessed. The physician experts, who based their decisions on available documentation in the case files, described uncertainties, particularly due to insufficient information relevant to the decision (e. g., on diagnostics, course of disease and treatment, weighting of existing limitations) in the nursing experts' assessments. Across all criteria, the experts' own professional or private rehabilitation experience and their understanding of the role of rehabilitation before and during the need for long-term care, as well as aspects of communication practice and the professional exchange between the nursing and the physician experts also influenced the overall decision-making process.

CONCLUSION

The identification of uncertainties in experts' decision-making process and associated factors enables the development of strategies to strengthen specifically the certainty of experts' decision-making and thus may contribute to the promotion of a needs-based rehabilitation access via long-term care assessment.

Use of a job exposure matrix to predict the risk of work disability in individuals with back pain: An inception cohort study

BACKGROUND

Low back pain has a high economic burden in Germany due to back pain-related sick leave, disability pensions, and health care utilization. Work-related factors can predict disabling back pain. Job exposure matrices can be used to consider job demands and occupational characteristics in routine data analysis.

OBJECTIVE

This longitudinal analysis tested whether rehabilitation utilization due to musculoskeletal disorders is associated with occupation-linked job exposures in employees with back pain.

METHODS

Data from a German cohort study were used, including employees aged 45 to 59 years with self-reported back pain in the last three months. Individuals' job titles were assessed in the baseline survey in 2017 and matched with parameters of aggregated job exposure indices. Administrative data from the German Pension Insurance were used to extract information on rehabilitation utilization. Proportional hazard models tested the associations.

RESULTS

We considered data of 6,569 participants (mean age: 52.3 years; 57.7% women). During follow-up, with a maximum of 21 months, 296 individuals (4.5%) utilized medical rehabilitation due to musculoskeletal disorders. Adjusted analyses showed that high physical (HR = 2.87; 95% CI 1.74; 4.75) and overall (HR = 2.34; 95% CI 1.44; 3.80) job exposures were associated with a higher risk of rehabilitation utilization.

CONCLUSION

Individuals with back pain working in occupations with high physical job exposures have a higher risk for rehabilitation utilization. To prevent work disability in individuals with back pain, occupational groups with high physical job exposures should be actively informed about tailored intervention options.

[Comprehension and Perspectives of the Need for Medical Rehabilitation - Results of a German Online Survey]

BACKGROUND

In Germany, medical rehabilitation usually requires an application of the persons in need. Therefore, these persons have to understand what rehabilitation is and in what case they need this type of health care service. In addition to people with health problems, their close persons (e. g. family members) should also have rehabilitation-related knowledge. Since there is only limited data on the perspective towards medical rehabilitation services, a survey was conducted.

METHOD

In September 2020, we invited 2,401 registered participants (age: 18-79 years) of a population-based online panel study to participate in an online survey. The cross-sectional survey asked about the understanding of need, subjective information as well as attitudes and expectations towards medical rehabilitation services. We analysed the data descriptively, taking into account the participants' rehabilitation experience and health impairment. In a subgroup analysis, the potential factors influencing the subjective need for rehabilitation were tested using logistic regression.

RESULTS

Data from 1,464 persons (Ø age: 52.5±14.5 years; 55% non-male) were analysed, 44% of the participants considered themselves to be "rather well" or "very well" informed about medical rehabilitation. The majority associated a need for rehabilitation with the access requirements related to service providers. In case of an emerging need for rehabilitation, family doctors would be the first point of contact. The participants mainly had function-oriented expectations of rehabilitation services and a majority prefer inpatient rehabilitation if necessary. Among 383 persons with long lasting and pronounced health-related impairment, the concrete individual need for rehabilitation was associated by a higher subjective degree of impairment as well as their own previous rehabilitation experience and rehabilitation experience in their personal social environment.

CONCLUSION

Despite an overall good understanding of the need for rehabilitation, different rehabilitation views were found in certain population groups. In order to improve the general understanding of rehabilitation in the public and particularly in close persons, adequate dissemination of low-threshold, population-based rehabilitation information is recommended.

Effectiveness of medical rehabilitation in persons with back pain - lessons learned from a German cohort study

PURPOSE

Evidence for health-related effects of German medical rehabilitation programs for back pain is inconclusive. This cohort study aimed to examine the effectiveness of medical rehabilitation in residents with back pain (German Clinical Trial Register: DRKS00011554).

MATERIAL AND METHODS

A sample of 45 000 people aged 45-59 years was randomly drawn from two pension agencies. We used propensity score matching to compare persons with back pain who completed a medical rehabilitation program with similar untreated subjects. Questionnaire data were assessed in 2017 and 2019, and linked with administrative data. The primary outcome was pain disability.

RESULTS

In total, 6610 persons with back pain were considered for matching and we finally compared 200 persons treated in a medical rehabilitation program with 200 untreated subjects. Pain disability was reported more favorable in the control group without medical rehabilitation compared to the intervention group (difference = 4.2; 95% CI -0.8-9.2), as well as other secondary outcomes.

CONCLUSIONS

At first glance, the findings suggest that medical rehabilitation was ineffective in improving health, pain and work ability among employed persons with back pain, but we found plausible explanations indicating that the estimated effects in favor of the untreated subjects are methodologically induced.IMPLICATIONS FOR REHABILITATIONPropensity score matching can be used to assess the effects of multimodal interventions in persons with back pain in routine care.Inappropriate recruitment of controls may underestimate treatment effects.When using observational data and propensity score matching to analyze the effectiveness of medical rehabilitation, baseline survey should be conducted directly before the start of rehabilitation to identify comparable controls.

Development and Evaluation of a Multimodal Supportive Intervention for Promoting Physical Function in Older Patients with Cancer

Physical function (PF) in older patients with cancer may decline during and after oncologic therapy. This study aimed to develop and pilot test an individually tailored unsupervised physical activity (PA) program and dietary recommendations to promote PF in older patients with cancer. Following development and pretest, the intervention was pilot tested to explore feasibility, acceptance, adherence and potential benefit. Patients ≥60 years, with heterogeneous cancer diagnoses, starting outpatient radiotherapy were randomized in two study arms: paper-based vs. video-based instructions. Based on assessments of PF, PA, nutrition, cognition, mental health, social support, HRQOL and personal goals, participants received individual recommendations for PA and nutrition. After 12 weeks of intervention (T1), reassessments were performed. The postal 4-week follow-up questionnaire included PA, nutrition and HRQOL. Participants (n = 24, 14 female, mean age 70 ± 7 years) showed comparable characteristics in both study arms. The majority rated the program as helpful. Facilitators and barriers to PA adherence were collected. Both modes of instructions were appreciated equally. PF (EORTC QLQ-C30) declined slightly (not clinically relevant >10 pts.) at group level T0: 76 ± 16, T1: 68 ± 21, T2: 69 ± 24. The intervention was feasible, well accepted, showing potential benefit for the maintenance of PF during outpatient radiotherapy, and should be further tested in a larger sample.

Work ability score as predictor of rehabilitation, disability pensions and death? A German cohort study among employees with back pain

BACKGROUND

Sickness absence, disability pensions, and use of healthcare due to disabling back pain are a high economic burden in Germany. Assessment are needed to identify employees who are likely to need intensive support.

OBJECTIVE

The cohort study examined whether rehabilitation, disability pensions and death can be predicted by a simple self-reported rating of work ability in employees with back pain in Germany.

METHODS

Employees aged 45 to 59 years who reported back pain in the last 3 months completed the Work Ability Score in 2017 (0-10 points). Individual scores were categorized into poor (0-5 points), moderate (6-7) and at least good (8-10) work ability. Outcomes were extracted from administrative records covering the period until the end of 2018. Proportional hazard models were fitted to determine the prognostic benefit of the Work Ability Score.

RESULTS

Data for 6,917 participants were included (57.8% women). The median follow-up time was 20 months. Of the participants, 52.1% had a good or excellent, 27.7% a moderate, and 20.2% a poor Work Ability Score. During follow-up, 548 persons were granted rehabilitation measures, 57 persons disability pensions, and 23 died. Fully adjusted analyses showed an increased risk of a rehabilitation measure (hazard ratio = 2.65; 95% CI 2.11; 3.34) and a disability pension (HR = 4.12; 95% CI 2.02; 8.39) in employees with poor work ability. A premature death was not associated with poor work ability.

CONCLUSIONS

The Work Ability Score is a potential tool to identify individuals, reporting back pain, with an increased risk of health-related early retirement and work disability.

Rehabilitation utilization of non-migrant and migrant persons with back pain: A cohort study using different definitions of migrant background

BACKGROUND

Medical rehabilitation (MR) by the German Pension Insurance is approved to maintain and to restore work ability and to avoid disability pensions. Studies on the rehabilitation utilization by people with a migration background (PMB) compared to people without a migration background (non-PMB) showed heterogeneous results, which may be partly due to different definitions of migration status. The aim of this paper was to test whether there are differences in utilization of MR between employed PMB and non-PMB with self-reported back pain.

METHODS

We used data from a large German cohort study that analyzed the effectiveness of MR for individuals with back pain and was conducted between 1st January 2017 and 31st December 2019. Employees aged 45 to 59 years who reported back pain in the last three months completed the baseline questionnaire in 2017. We used four definitions of migration background (MB) to differentiate by first- and second-generation migration, by one- and two-sided migration background, by language, or by nationality. Data on rehabilitation utilization was extracted from administrative records covering the period until the end of 2018.

FINDINGS

Data of 6,713 participants were included, and 514 individuals utilized MR during follow-up. Adjusted analyses showed a decreased risk of rehabilitation utilization in people with a first-generation MB (HR = 0·46; 95% CI 0·29; 0·72), people with a two-sided MB (HR = 0·47; 95% CI 0·31; 0·72), people whose native language was not German (HR = 0·52; 95% CI 0·30; 0·91), and people without German nationality (HR = 0·29; 95% CI 0·12; 0·72) when compared to non-PMB.

INTERPRETATION

This study showed that employees with a MB reporting back pain had a significantly reduced risk for utilization of rehabilitation services. This underutilization could be observed considering different definitions of MB. Future research on rehabilitation utilization by PMB should consider the impact of different definitions on the results.

FUNDING

The study was funded by the German Research Foundation (grant numbers: BE 5885/2-1; MA 6981/2-1). The German Research Foundation functions as a self-governing institution for the promotion of science and research in Germany.

Barriers to applying for medical rehabilitation: a time-to-event analysis of employees with severe back pain in Germany

OBJECTIVE

Longitudinal studies on barriers to applying for rehabilitation in Germany are lacking in light of the suspected underutilization of rehabilitation services. The aim of this study was to examine application behaviour in persons with disabling back pain and to identify relevant predictors for making an application.

DESIGN

A prospective cohort study with randomized sampling of insurants in the German Pension Insurance, using a questionnaire at baseline and follow-up with linked administrative data for 1.5 years.

SUBJECTS/PATIENTS

Employed persons (age range 45-59 years) with a high degree of limitations due to back pain and a self-reported risk of permanent work disability (not applied for disability pension, no medical rehabilitation within the last 4 years).

METHODS

Multivariable Cox regression was used to examine the influence of pre-selected variables on making an application in the follow-up period.

RESULTS

Of 690 persons, only 12% applied for rehabilitation. Predictors for making an application were: support from physicians (hazard ratio (HR)=2.24; 95% confidence interval (95% CI) 1.32-3.80), family, and friends (HR=1.67; 95% CI 1.02-2.73), more pain-related disability days (HR=1.02; 95% CI 1.01-1.03), and worse work ability (HR=0.86; 95% CI 0.75-0.97). An intention to apply at baseline mediated the effect of family and physician support on the application.

CONCLUSION

The low number of applications for rehabilitation despite disabling back pain indicates access barriers to, and underuse of, medical rehabilitation.

Self-Reported Prognosis of Employability as an Indicator of Need for Rehabilitation: A Cohort Study in People with Back Pain

PURPOSE

Rehabilitation is a key strategy to enable people with disabilities or chronic diseases to participate in society and employment. In Germany, the approval of rehabilitation services is linked to personal requirements, including significantly compromised work ability due to illness. The subjective prognosis of employability (SPE) is a brief 3-item scale. The total score assesses the self-rated risk of permanent work disability and was therefore proposed to be an indicator to operationalize the requirements to determine the need for a medical rehabilitation measure. This cohort study examined whether rehabilitation and disability pensions can be predicted by the SPE in employees with back pain. Moreover, the study tested the applicability of the SPE regarding interrupted employment.

METHODS

Employees aged 45 to 59 years who reported back pain in the last three months completed the SPE in 2017. The total score ranges from 0 to 3 points, with higher values indicating a higher risk of permanent work disability. Data on rehabilitation, disability pensions, and interrupted employment were extracted from administrative records covering the period until the end of 2018. Proportional hazard and logistic regression models were fitted.

RESULTS

Data of 6,742 participants were included (mean age: 52.3 years; 57.8% women). Maximum follow-up was 21 months. Of the participants, 38.8, 33.6, 21.4, and 6.2% had an SPE score of 0, 1, 2, and 3 points, respectively. During follow-up, 535 individuals were approved for a rehabilitation measure and 49 individuals for a disability pension. Fully adjusted analyses showed an increased risk of a rehabilitation in employees with an SPE score of 3 points (HR=2.20; 95% CI 1.55; 3.11) and 2 points (HR=1.76; 95% CI 1.33; 2.31) compared to employees with an SPE score of 0 points. The risk of a disability pension (HR=13.60; 95% CI 4.56; 40.57) and the odds of interrupted employment (OR=2.58; 95% CI 1.72; 3.86) were also significantly increased for those with an SPE score of 3 points.

CONCLUSIONS

The brief SPE is an appropriate tool to identify individuals reporting back pain at risk of rehabilitation, poor work participation outcomes, and permanent work disability.

HINTERGRUND

Rehabilitation ist eine Schlüsselstrategie, um Menschen mit Behinderungen oder chronischen Erkrankungen die Teilhabe an der Gesellschaft und am Arbeitsleben zu ermöglichen. In Deutschland ist die Bewilligung von Rehabilitationsleistungen an persönliche Voraussetzungen geknüpft, u. a. an eine erhebliche Gefährdung der Erwerbsfähigkeit aufgrund von Krankheit. Die subjektive Erwerbsprognose (SPE) ist eine kurze 3-Item-Skala. Der Gesamtscore bewertet das selbst eingeschätzte Risiko einer dauerhaften Arbeitsunfähigkeit und wurde daher als Indikator zur Operationalisierung der Voraussetzungen und zur Bestimmung des Bedarfs an einer medizinischen Rehabilitationsmaßnahme vorgeschlagen. Die Kohortenstudie untersucht, inwiefern Rehabilitationen und Erwerbsminderungsrenten durch die SPE bei Beschäftigten mit Rückenschmerzen vorhergesagt werden können. Zudem wurde die Assoziation zwischen der SPE und unterbrochener Beschäftigung getestet.

METHODEN

Die SPE wurde im Jahr 2017 bei Versicherten im Alter von 45 bis 59 Jahren, die Rückenschmerzen in den letzten drei Monaten berichteten, erhoben. Der Gesamtscore reicht von 0 bis 3 Punkten, wobei höhere Werte ein höheres Risiko für eine dauerhafte Erwerbsunfähigkeit anzeigen. Daten zu Rehabilitationen, Erwerbsminderungsrenten und unterbrochener Beschäftigung umfassen den Zeitraum bis Ende 2018 und wurden aus den Versichertenkonten extrahiert. Die Zusammenhänge wurden mittels proportionaler Hazard- und logistischer Regressionsmodelle getestet.

ERGEBNISSE

Es wurden die Daten von 6.742 Teilnehmenden eingeschlossen (mittleres Alter: 52,3 Jahre; 57,8% weiblich). Der maximale Nachbeobachtungszeitraum betrug 21 Monate. 38,8, 33,6, 21,4 und 6,2% hatten einen SPE-Score von 0, 1, 2 bzw. 3 Punkten. Im Beobachtungszeitraum wurde 535 Personen eine Rehabilitationsmaßnahme und 49 Personen eine Erwerbsminderungsrente bewilligt. Vollständig adjustierte Analysen zeigten ein erhöhtes Risiko für eine Rehabilitation bei Beschäftigten mit einer SPE von 3 Punkten (HR=2,20; 95% KI 1,55; 3,11) und 2 Punkten (HR=1,76; 95% KI 1,33; 2,31) im Vergleich zu Personen mit einer SPE von 0 Punkten. Das Risiko einer Erwerbsminderungsrente (HR=13,60; 95% KI 4,56; 40,57) und die Wahrscheinlichkeit für eine unterbrochene Beschäftigung (OR=2,58; 95% KI 1,72; 3,86) waren ebenfalls signifikant erhöht für diejenigen mit einer SPE von 3 Punkten.

SCHLUSSFOLGERUNGEN

Die SPE ist bei Menschen mit selbstberichteten Rückenschmerzen ein geeignetes Assessmentinstrument zur Identifizierung von Personen, bei denen ein erhöhtes Risiko für eine Rehabilitation, gefährdete berufliche Teilhabe und dauerhafte Arbeitsunfähigkeit besteht.

[Factors Influencing the Access to and Utilization of Medical Rehabilitation Services Recommended after Care Assessment - Results of Qualitative Interviews with Professionals Involved in the Decision Process]

PURPOSE

In Germany, persons in need of care can receive a rehabilitation recommendation from the medical service of the health insurance companies. Approximately half of these recommendations lead to applications and every fourth recommendation to actual utilisation of medical rehabilitation. Little is known about the supporting factors for and barriers to this special access to medical rehabilitation for persons in need of care. To explore the influencing factors - both personal and procedural - from the perspectives of involved professionals.

METHODS

Interviews regarding on the access to medical rehabilitation were conducted with expert raters from the medical service of the German statutory health insurance system and with employees in long-term care and in health insurance. For data analysis systematic text condensation was used.

RESULTS

Based on 53 interviews with 56 involved professionals, individual- and process-related influencing factors were identified. In addition to sociodemographic, health-related, personal and financial characteristics, rehabilitation-related attitudes and a strong attachment to the home environment seem to be particularly relevant. Furthermore, service-related (e. g. expectations and wishes) and process-related (e. g. care structures) characteristics also seem to have an impact. The importance of social support from relatives was emphasized.

CONCLUSIONS

The results point to potential supporting factors and barriers in the access to rehabilitation by means of care assessment. They should be considered for possible improvements of the assessment and approval procedures as well as the necessary early and sufficient councelling of the concerned persons and their relatives.

Employability and intention to apply for rehabilitation in people with back pain: A cross-sectional cohort study

OBJECTIVES

To analyse the association between self-reported prognosis of employability and health-related measures, and to clarify which determinants influence the intention to apply for medical rehabil-itation.

DESIGN

Cross-sectional study of a random sample of German employees.

PARTICIPANTS

A total of 6,654 participants (58% female) aged 45-59 years with back pain during the last 3 months.

RESULTS

Out of a total of 6,654 persons, 4,838 had a positive self-reported prognosis of employability. Persons with positive and negative prognoses clearly differ with regard to health-related measures. Of 1,816 persons who reported a negative prognosis, 26% stated an intention to apply for rehabilitation. Intention was determined mainly by perceived social support from family and friends (odds ratio (OR) 1.87; 95% confidence interval (95% CI) 1.66-2.10), as well as physicians and therapists (OR 1.64; 95% CI 1.41-1.90).

CONCLUSION

A negative self-reported prognosis of employability is associated with self-reported health restrictions that may determine the need for rehabilitation interventions. A considerable proportion of persons with self-reported health restrictions do not plan to use medical rehabilitation. Perceived social support is an important facilitator of intention to apply for rehabilitation. However, this study needs to be replicated in other populations combining self-reported and administrative data.

[Determinants of the Wish for Rehabilitation and the Intention to Apply in Persons with Back Pain]

PURPOSE

Up to now, the main focus of analysis has been on determinants of the application for and utilization of medical rehabilitation due to back pain. The prevalence and determinants of motivational and volitional preceding stages of the application have not yet been well examined. Therefore, this study analyses the prevalence and determinants of the wish for rehabilitation and the intention to apply.

METHODS

Data were derived from the baseline survey of a cohort study including a sample of 45,000 persons randomly drawn from the statutory pension agencies (GPI North and GPI Central Germany). The baseline data of persons aged 45-59 years with back pain within the past 3 months, neither receiving disability pension nor medical rehabilitation during the past 4 years were analysed. Determinants of the wish for rehabilitation and the intention to apply were identified using multivariate logistic regression analyses.

RESULTS

2,348 of the 6,549 persons with back pain (36%) wished to participate in a rehabilitation program. Of these 774 (33%) declared their intention to apply. Both dependent variables were strongly associated with the social support by family and friends. The wish for rehabilitation was also strongly determined by the previous experience with rehabilitation services. Another important determinant of the intention to apply was the support by physicians and therapists. Other factors were found to influence both dependent variables differently.

CONCLUSION

In order to improve the need-based access to rehabilitation, the preceding stages (wish for rehabilitation and intention to apply) and their partly different determinants should be considered. The support by family and friends as well as physicians and therapists are important. This is a further indication that information and the involvement of these actors are key elements to ensure an acquired access to rehabilitation.

[Database indexing of health science journals from the German-speaking area: A journal analysis]

BACKGROUND

Journal hand searching offers the possibility to complement a literature search as part of systematic reviews and other evidence syntheses. Hand searching is indicated in cases where scientific journals with potentially relevant publications addressing the research question are not indexed in a literature database. However, it is often unclear whether these journals are actually indexed, and when they are, in which literature databases. In many cases, it is also unknown which journals should be searched by hand in addition to systematic literature search after databases to be searched have been specified. Therefore, the project aimed to investigate the indexation of selected scientific health science journals and to provide an overview of indexation in order to facilitate the hand search planning process.

METHODS

Journals from German-speaking countries covering eight professional fields (medical laboratory assistance, occupational therapy, midwifery, logopedics, nursing, physiotherapy, public health and rehabilitation) were considered that publish original research papers or systematic reviews or other review types in German and/or English. Two researchers per field identified relevant journals and independently analyzed the indexing locations using the journal websites. In case of missing information, we contacted the editors.

RESULTS

A total of 70 journals were included: from 1 to 17 journals per field. These journals are indexed in 1 to 29 databases. Twelve journals are not indexed or do not offer information concerning indexation. Indexation is distributed across n=74 different literature databases. Most journals are indexed in LIVIVO (n=55) and bibnet.org (n=33). Other common indexing databases are Scopus (n=18), Web of Science Core Collection (n=16), PSYNDEX (n=13), and Embase (n=10).

CONCLUSIONS

The results indicate a heterogeneous indexation of the included journals. Only a small number is indexed in common international literature databases such as MEDLINE or CINAHL. On the other hand, only a few journals are not indexed in any database. The results can be used as a basis to define databases for literature searches as part of systematic reviews. In addition, the findings might guide the selection of journals for hand searching after literature databases have been defined.

[Promotion of physical activity for older patients with rheumatism : Characteristics of inflammatory rheumatic diseases against the background of physical activity recommendations]

Due to the wide range of positive effects and the clear evidence of effectiveness, physical activity is one of the most important treatments for inflammatory rheumatic diseases. Because of the frequent overlap of disease and age-related aspects in older patients, the implementation of the German national physical activity recommendations has to be checked and accompanied by physicians. To get the older patients in motion, a patient-centered approach is required that takes the individual health problem(s) and the current context of life into account. This article provides an overview of the activity-related characteristics of older patients with inflammatory rheumatic diseases. Against this background a simple strategy is provided for promoting physical activity during medical consultation, which takes the characteristics of older patients with rheumatism into consideration. In this way, physicians can integrate a targeted, resource and time-saving economic strategy into consultations that is in concordance with the national physical activity recommendations.

Multimodale Supportivintervention zur Förderung der körperlichen Funktionsfähigkeit älterer Krebspatientinnen und Krebspatienten

Hintergrund Ältere Menschen mit Tumorerkrankungen sind heterogen in Bezug auf biologisches Alter, körperliche und kognitive Funktionalität sowie Anzahl und Schwere von Komorbiditäten. Daher wird empfohlen, vor der Planung einer onkologischen Therapie ein umfassendes geriatrisches Assessment durchzuführen, um individuelle Risikofaktoren und Ressourcen zu identifizieren. Trotz angepasster Therapien kann jedoch unter onkologischer Behandlung die körperliche Funktion nachlassen, was zu einer Gefährdung der Alltagsfunktionalität und Selbstversorgung sowie zu einer Reduktion der gesundheitsbezogenen Lebensqualität (HRQOL) führen kann. Um dieser Entwicklung entgegenzuwirken und die Selbstständigkeit zu erhalten, sind gezielte supportive Strategien unter Berücksichtigung der individuellen Plastizität erforderlich. Ziel dieser Studie ist daher die Entwicklung und Pilotierung einer multimodalen Intervention zur Förderung der körperlichen Aktivität älterer Patientinnen und Patienten unter und nach ambulanter strahlentherapeutischer Behandlung.

Methodik Das methodische Vorgehen basiert auf der Richtlinie des UK MRC Frameworks zur Entwicklung komplexer Interventionen. Mit dem Ziel die Alltagsfunktionalität auch unter Therapie möglichst zu erhalten, beinhaltet die im häuslichen Umfeld durchführbare Intervention Module zur körperlichen Aktivierung und Ernährung. Basierend auf umfassenden Assessments von körperlicher Funktion, aktuellen Aktivitäten, Ernährungsstatus, Kognition, Depression, sozialer Unterstützung, Lebensqualität, Motivation und persönlichen Zielen werden individuelle Trainingsempfehlungen und Ernährungshinweise formuliert. Im Rahmen von Pretests mit Krebsüberlebenden werden die Inhalte der Interventionsmodule und die Materialien zur Anleitung auf Eignung und Verständlichkeit geprüft und ggf. optimiert.

Ausblick In der anschließenden Pilotierung werden Patientinnen und Patienten der Altersgruppen 60+, 70 + und 80+, die sich einer ambulanten Strahlentherapie unterziehen, in 2 Gruppen (papier-basierte oder elektronisch gestützte, video-basierte Anleitungen) randomisiert, um die Intervention und die unterschiedlichen Ansprechwege auf Machbarkeit, Akzeptanz und potentiellen Nutzen zu prüfen.

Home-based balance training using Wii Fit™: a pilot randomised controlled trial with mobile older stroke survivors

Background

Several studies have reported that using the Wii™ Balance Board can provide added value regarding balance (re-)training in neurological diseases. However, for the large group of mobile older stroke survivors, there is no evidence regarding the feasibility of an unsupervised Wii™ Balance Board training in the home setting. The aim of this study was to investigate the feasibility of a home-based Wii™ balance training for these patients and to identify methodological challenges for randomised controlled trials in the future.

Methods

We conducted a pilot randomised controlled trial with two intervention arms in participants' homes. Mobile stroke survivors (aged 60 years or above; 12 weeks after discharge from hospital) received a 6-week (once per week) supervised balance training at the study centre, followed by a 6-week (three times per week) unsupervised balance training at home. We used the Nintendo Wii™ Balance Board for one intervention arm and conventional balance exercises for the other intervention arm. Feasibility was assessed by recruiting rates, appropriateness of assessments regarding sensitivity to changes and acceptance of the intervention by the participants.

Results

In two German hospital stroke units, 349 stroke survivors were screened over a period of 6 months, 91 were eligible and 52 were interested. Twelve weeks after discharge, 14 participants agreed and 11 completed the intervention (7 men and 4 women, mean age 74 years). The Berg Balance Scale and Dynamic Gait Index showed ceiling effects already at baseline measure. The participants in both intervention arms evaluated the unsupervised training positively and feasible for self-application. No falls or injuries occurred over the intervention period, while the required scope of the exercises could largely be achieved.

Conclusions

In this pilot study, the recruitment of participants and the chosen assessments were not satisfactory due to selection bias and corresponding ceiling effects. However, the two home-based balance interventions proved feasible for mobile older stroke survivors with low functional limitations.

Trial registration

ClinicalTrials.gov, NCT02251470. Registered 29 September 2014.

Weighting schemes in pooled linkage analysis

To identify susceptibility gene regions for complex diseases a combined linkage analysis of several genome scans might give additional insights to individual studies. In this article we consider different weighting schemes to combine the score statistics of individual studies to an overall statistic within multipoint nonparametric linkage analysis by GENEHUNTER/ALLEGRO. With the Genetic Analysis Workshop (GAW) 12 asthma data sets the weights are dominated by the large differences in the relevant sample sizes.

Genotype-phenotype analysis in Apert syndrome suggests opposite effects of the two recurrent mutations on syndactyly and outcome of craniofacial surgery

Apert syndrome is an autosomal dominant condition characterized by craniosynostosis and severe syndactyly, caused by two recurrent mutations in the fibroblast growth factor receptor 2 gene (FGFR2). The genotype-phenotype correlations of 21 patients with Apert syndrome were analysed as to the craniofacial appearance following surgery and the degree of syndactlyly. The craniofacial appearance following craniofacial surgery was better in patients with the P253R mutation, whereas these patients showed a more pronounced severity of the syndactyly.

Nonsyndromic X-linked mental retardation: mapping of MRX58 to the pericentromeric region

An Austrian family with nonsyndromic X-linked mental retardation (MRX) is reported in which the obligatory carrier females are normal, and 5 affected males have mild to moderate mental retardation. Linkage analysis indicated an X pericentromeric localization, with flanking markers DXS989 and DXS1111 and a maximum multipoint LOD score of 2.09 (straight theta = 0) for the 7 cosegregating markers DXS1243, CybB, MAOB, DXS988, ALAS2, DXS991, and AR. MRX58 thus mapped within a 50-cM interval between Xp11.3 and Xq13.1 and overlapped with 23 other MRX families already described. This pericentromeric clustering of MRX families suggests allelism, with a minimum of 2 X-linked mental retardation (XLMR) genes in this region.

Detection of 100% of the CFTR mutations in 63 CF families from Tyrol

We identified 100% of the CFTR gene mutations, including three novel mutations, in 126 unrelated cystic fibrosis chromosomes from Tyrol, Austria. The frequency of the major mutation deltaF508 (74.6%) was not significantly different in Tyrolian CF-patients than in patients from Bavaria (71.0%) and Middle- and Northern Germany (71.9%), but was significantly higher than in patients from Styria (58.1%) or Northern Italy (47.6%). Interestingly, the distribution of the next most frequent mutations, R1162X (8.7%) 2183AA-->G, 2789+5G-->A and G542X (2.4% each), was more similar to the distribution of these mutations among CF-patients from Northern Italy than to those from Styria, Bavaria or Middle- and Northern Germany. Nine further mutations occurred once or twice. One of these, the missense mutation M1101K, is rare worldwide but very frequent in the Hutterite brethren, a small founder population which came from Southern Austria to Northern America. Three other different mutations (deltaL453, 1874insT and 4108delT) were present in single Tyrolian families and have not been described before. The identification of 100% of CFTR gene mutations in a particular CF population demonstrates the power of genetic analysis for the diagnosis and counselling of CF families in this restricted geographical area of Austria. Our study provides evidence for a closer genetic relation between CF patients from Tyrol and those from Bavaria or Middle- and Northern Germany as well as Northern Italy, than between CF patients from the two Austrian states Tyrol and Styria.

Phenotypic expression of the fibroblast growth factor receptor 3 (FGFR3) mutation P250R in a large craniosynostosis family

The craniosynostosis syndromes are a heterogeneous group of sporadic, autosomal dominant disorders with significant clinical overlap. Recently, we described a large family with autosomal dominant craniosynostosis suggestive of Saethre-Chotzen syndrome, in which linkage to the Saethre-Chotzen syndrome loci on 7p had been excluded. We now report the presence of a mutation in the fibroblast growth factor receptor 3 (FGFR3) in this family. The mutation, P250R, had been previously reported in 10 patients with non-syndromic craniosynostosis. Variable expression of this mutation is evident especially in two additional members of this family, one of whom is severely affected with pancraniosynostosis. The family provides a further example of genetic heterogeneity and variable expression of the craniosynostosis syndromes and broadens the phenotypic spectrum associated with the FGFR3 mutation P250R. In addition, we found a polymorphism (F384L) in the transmembrane domain of FGFR3 which occurs with a frequency of 3% in the Turkish population but is uncommon among Germans.

Regional localization of two MRX genes to Xq28 (MRX28) and to Xp11.4-Xp22.12 (MRX33)

Two genes responsible for a nonspecific form of X-linked mental retardation (MRX28 and MRX33) were localized by linkage analysis with 40 highly polymorphic DNA markers situated along the entire the X chromosome. In family 1, the gene could be mapped within a 14-cM interval at Xq28, distal to the recombining marker DXS1113 (MRX28). The maximum LOD score was 2.75, with DXS52 at phi = .0. In family 2, the gene was localized within a 30-cM interval at Xp11.4-22.12 between the recombining markers DXS365 and MAOB, including the DMD gene (MRX33). Maximum LOD scores of 2.82 were obtained with markers DMD-STR49, DMD-DysII, CYBB, and DXS1068.

Wiskott-Aldrich syndrome: no strict genotype-phenotype correlations but clustering of missense mutations in the amino-terminal part of the WASP gene product

The Wiskott-Aldrich syndrome protein (WASP) gene was found to be mutated in patients presenting with WAS and in patients showing X-linked thrombocytopenia. Mutation analysis in 19 families of German, Swiss and Turkish descent by single-strand conformation polymorphism and sequencing resulted in the detection of seven novel and 10 known mutations. A striking clustering of missense mutations in the first four exons contrasted with a random distribution of nonsense mutations. More than 85% of all known missense mutations were localized in the amino-terminal stretch of the WASP gene product; this region contained a mutational hot spot at codon 86. No genotype-phenotype correlation emerged after a comparison of the identified mutations with the resulting clinical picture for a classical WAS phenotype. A substitution at codon 86 resulted in an extremely variable expression of the disease in a large Swiss family. An extended homology search revealed a distant relationship of this stretch to the vasodilator-stimulated phosphoprotein (VASP), which is involved in the maintenance of cyto-architecture by interacting with actin-like filaments.

Geographic distribution and origin of CFTR mutations in Germany

The geographic distribution and origin of CFTR mutations in Germany was evaluated in 658 three-generation families with cystic fibrosis (CF). Fifty different mutations were detected on 1305 parental CF chromosomes from 22 European countries and overseas. The major mutation. delta F508 was identified on 71.5% of all CF chromosomes, followed by R553X (1.8%), N1303K (1.3%), G542X (1.1%), G551D (0.8%) and R347P (0.8%). According to the grandparents' birthplace, 74% of CF chromosomes had their origin in Germany; the delta F508 percentage was 77%, 75%, 70% and 62% in northern, southern, western and eastern Germany, respectively. Ten or more mutant alleles in the investigated CF gene pool originated from Austria, the Czech Republic, Poland, Russia, Turkey and the Ukraine. This widespread geographic origin of CFTR mutations in today's Germany reflects the many demographic changes and migrations in Central Europe during the 20th century.

Craniosynostosis suggestive of Saethre-Chotzen syndrome: clinical description of a large kindred and exclusion of candidate regions on 7p

We describe the clinical manifestations of an autosomal dominant form of craniosynostosis in a large family with eight affected relatives. Unilateral or bilateral coronal synostosis, low frontal hair line, strabismus, ptosis, and partial cutaneous syndactyly of fingers and toes are findings suggestive of the diagnosis of Saethre-Chotzen syndrome. The disease locus was excluded from the two adjacent Saethre-Chotzen candidate regions on 7p by linkage analysis with markers D7S664 and D7S507. This indicates heterogeneity of Saethre-Chotzen syndrome with a locus outside the candidate regions on 7p.

An evaluation of FASTMAP with emphasis on fine-mapping

We present an evaluation of the FASTMAP method with special reference to the issue of fine-mapping, using both 'real-life' and constructed data, and demonstrate some of the shortcomings of the method. Since the advantages of FASTMAP in terms of savings in computer resources compared to LINK-MAP are enormous, further improvements of the FASTMAP method would be highly desirable.

Exclusion of malignant hyperthermia susceptibility (MHS) from a putative MHS2 locus on chromosome 17q and of the alpha 1, beta 1, and gamma subunits of the dihydropyridine receptor calcium channel as candidates for the molecular defect

Malignant hyperthermia (MH) is a potentially lethal pharmacogenetic disease with autosomal dominant inheritance triggered by exposure to commonly used inhalational anaesthetics or depolarising muscle relaxants. A MHS locus has been identified on human chromosome 19q12-q13.2 and the gene for the skeletal muscle calcium release channel of sarcoplasmic reticulum (ryanodine receptor) (RYR1) is considered a candidate for the molecular defect. However, MH has been shown to be genetically heterogeneous, and in the ensuing search for other MHS genes, a locus on chromosome 17q has been proposed, and the gene for the adult muscle sodium channel (SCN4A) was suggested as a candidate. We performed linkage studies using polymorphic microsatellite markers for subunits of the skeletal muscle dihydropyridine (DHP) receptor, CACNL1A3 mapped to chromosome 1q, as well as C-ACNLB1 and CACNLG, the latter two localised on chromosome 17q11.2-q24 in proximity to the proposed MHS2 and the SCN4A loci, and we also included markers for the loci D17S250, D17S579, NM23 (NME1), GH1, and SCN4A from that region. Our results exclude the alpha 1, beta 1 and gamma subunit of the DHP receptor as well as the SCN4A locus from that region. Our results exclude the alpha 1, beta 1, and gamma subunit of the DHP receptor as well as the SCN4A locus as candidates for the molecular defect in MHS for these pedigrees where also the RYR1 on chromosome 19q13.1 has been excluded. A multipoint analysis excludes the disease from the entire 84 cM interval containing the proposed MHS locus on chromosome 17q.(ABSTRACT TRUNCATED AT 250 WORDS)

Evidence for genetic heterogeneity of malignant hyperthermia susceptibility

A locus for malignant hyperthermia susceptibility (MHS) has been localized on chromosome 19q12-13.2, while at the same time the gene encoding the skeletal muscle ryanodine receptor (RYR1) also has been mapped to this region and has been found to be tightly linked to MHS. RYR1 was consequently postulated as the candidate for the molecular defect causing MHS, and a point mutation in the gene has now been identified and is thought to be the cause of MH in at least some MHS patients. Here we report the results of a linkage study done with 19q12-13.2 markers, including the RYR1 cDNA, in two Bavarian families with MHS. In one of the families, three unambiguous recombination events between MHS and the RYR1 locus were found. In the second family only one informative meiosis was seen with RYR1. However, segregation analysis with markers for D19S75, D19S28, D19S47, CYP2A, BCL3, and APOC2 shows that the crossovers in the first family involve the entire haplotype defined by these markers flanking RYR1 and, furthermore, reveals multiple crossovers between these haplotypes and MHS in the second family. In these families, pairwise and multipoint lod scores below -2 exclude MHS from an interval spanning more than 26 cM and comprising the RYR1 and the previously described MHS locus. Our findings thus strongly suggest genetic heterogeneity of the MHS trait and prompt the search for another MHS locus.

Definitive localization of X-linked Kallman syndrome (hypogonadotropic hypogonadism and anosmia) to Xp22.3: close linkage to the hypervariable repeat sequence CRI-S232

Kallmann syndrome is a genetically heterogeneous disease characterized by hypogonadotropic hypogonadism and anosmia. Six families in which the disorder followed an X-linked inheritance were investigated by linkage analysis. Diagnostic criteria were uniformly applied and included tests for hypogonadotropic hypogonadism and anosmia. Close linkage was found by using the hypervariable repeated sequence CRI-S232 (DXS278) previously mapped to Xp22.3. At a maximum lod score of 6.5, the recombination fraction was calculated as .03. Of 30 fully informative meioses, one recombination between the disease locus and the loci recognized by probe CRI-S232 was observed. When an independent approach is used, these results confirm the X-linked Kallmann syndrome assignment previously made by deletion mapping, and allow definitive localization of the syndrome assignment previously made by deletion mapping, and allow definitive localization of the syndrome to the Xp22.3 region. This opens the way to carrier detection and to the identification of a gene responsible for this disorder.