Effects on temporomandibular disorder in the treatment of tension-type headache with acupuncture and therapeutic exercises. A secondary analysis from a randomized controlled trial

OBJECTIVES

To examine the effects of acupuncture and therapeutic exercise alone and in combination on temporomandibular joint symptoms in tension-type headache and to evaluate the potential interaction of existing temporomandibular dysfunction on the success of headache treatment.

DESIGN

Pre-planned secondary analysis of a randomized controlled, non-blinded trial.

SETTING

Outpatient clinic of a German university hospital.

SUBJECTS

Ninety-six Participants with frequent episodic or chronic tension-type headache were randomized to one of four treatment groups.

INTERVENTIONS

Six weeks of acupuncture or therapeutic exercise either as monotherapies or in combination, or usual care. Follow-up at 3 and 6 months.

MAIN MEASURES

Subjective temporomandibular dysfunction symptoms were measured using the Functional Questionnaire Masticatory Organ, and the influence of this sum score and objective initial dental examination on the efficacy of headache treatment interventions was analyzed.

RESULTS

Temporomandibular dysfunction score improved in all intervention groups at 3-month follow-up (usual care: 0.05 [SD 1.435]; acupuncture: -5 [SD 1.436]; therapeutic exercise: -4 [SD 1.798]; combination: -3 [SD 1.504]; P = 0.03). After 6 months, only acupuncture (-6 [SD 1.736]) showed a significant improvement compared to the usual care group (P < 0.01). Subjective temporomandibular dysfunction symptoms had no overall influence on headache treatment.

CONCLUSIONS

Only acupuncture had long-lasting positive effects on the symptoms of temporomandibular dysfunction. Significant dental findings seem to inhibit the efficacy of acupuncture for tension-type headache.

Herausforderungen einer bedarfsorientierten Reha-Steuerung nach Oberschenkelamputation

Im internationalen Kontext wird unter Rehabilitation eine Gesundheitsstrategie verstanden 1, die durch verschiedene Maßnahmen auf verbesserte Funktionsfähigkeit zielt, um Teilhabeeinschränkungen zu reduzieren, die Menschen mit gesundheitlichen Beeinträchtigungen in der gesellschaftlichen Interaktion erfahren 2. Die aktuelle Resolution der Weltgesundheitsversammlung „Strengthening rehabilitation in health systems” 3 fordert in Übereinstimmung mit der UN-Behindertenkonvention 4, dass für die medizinischen Belange von Menschen mit Beeinträchtigungen adäquate Rehabilitationsdienste und Rehabilitationsprogramme zur Verfügung stehen müssen. Dies entspricht dem Prinzip einer bedarfsorientierten Leistungserbringung ohne Limitierung durch den Grad der Beeinträchtigung einer Person. Darüber hinaus sollen in allen Phasen der Gesundheitsversorgung diese Rehabilitationsdienste verfügbar sein, also vom Akutkrankenhaus bis zur Langzeitversorgung.

Health System's Role in Facilitating Health Service Access among Persons with Spinal Cord Injury across 22 Countries

(1) Background: Despite efforts to improve access to health services, between- and within-country access inequalities remain, especially for individuals with complex disabling conditions like spinal cord injury (SCI). Persons with SCI require regular multidisciplinary follow-up care yet experience more access barriers than the general population. This study examines health system characteristics associated with access among persons with SCI across 22 countries. (2) Methods: Study data are from the International Spinal Cord Injury Survey with 12,588 participants with SCI across 22 countries. Cluster analysis was used to identify service access clusters based on reported access restrictions. The association between service access and health system characteristics (health workforce, infrastructure density, health expenditure) was determined by means of classification and regression trees. (3) Results: Unmet needs were reported by 17% of participants: lowest (10%) in Japan, Spain, and Switzerland (cluster 1) and highest (62%) in Morocco (cluster 8). The country of residence was the most important factor in facilitating access. Those reporting access restrictions were more likely to live in Morocco, to be in the lowest income decile, with multiple comorbidities (Secondary Conditions Scale (SCI-SCS) score > 29) and low functioning status (Spinal Cord Independence Measure score < 53). Those less likely to report access restriction tended to reside in all other countries except Brazil, China, Malaysia, Morocco, Poland, South Africa, and South Korea and have fewer comorbidities (SCI-SCS < 23). (4) Conclusions: The country of residence was the most important factor in facilitating health service access. Following the country of residence, higher income and better health were the most important facilitators of service access. Health service availability and affordability were reported as the most frequent health access barriers.

Effects of acupuncture and medical training therapy on depression, anxiety, and quality of life in patients with frequent tension-type headache: A randomized controlled study

OBJECTIVES

To compare the effects of acupuncture and medical training therapy in combination or individually with usual care on quality of life, depression, and anxiety in patients with tension-type headache.

METHODS

In this single-center, prospective, randomized, controlled, unblinded trial, 96 adults (38.7(+/-13.3) years of age; 75 females/20 males/one dropout) with frequent episodic or chronic tension-type headache were randomized to one of four treatment groups (n = 24). The treatment groups received six weeks of either acupuncture or medical training therapy as monotherapies or in combination (12 interventions each), or usual care. We assessed depressiveness (PHQ-9), anxiety (GAD-7), and health-related quality of life (SF-12) as secondary outcome parameters at baseline, six weeks, three months, and six months after initiation of treatment. Linear mixed models were calculated.

RESULTS

Both, acupuncture (baseline to six-weeks change scores: mean: -2(standard deviation: 2.5 points), three months: -2.4(2.4), six-months -2.7(3.6)) and the combination of acupuncture and medical training therapy (-2.7(4.9), -2.2(4.0), -2.2(4.2)) (each within-group p < .05) significantly reduced depressiveness-scores (PHQ-9) to a greater extent than medical training therapy (-0.3(2.0), -0.5(1.6), -0.9(2.6)) or usual care alone (-0.8(2.9), 0.1(2.8), 0.2(3.6)). We found similar results with anxiety scores and the physical sum scores of the SF-12. No severe adverse events occurred.

CONCLUSIONS

Acupuncture and the combination of acupuncture and medical training therapy elicit positive effects on depression, anxiety, quality of life, and symptom intensity in patients with episodic and chronic tension-type headache. Acupuncture appears to play a central role in mediating the therapeutic effects, underscoring the clinical relevance of this treatment. An additive benefit of the combination of both therapies does not appear to be relevant.Trial registration: Registered on 11 February 2019. German Clinical Trials Register, DRKS00016723.

Test of the Rehabilitation Goal Screening (ReGoS) Tool to Support Decision Making and Goal Setting in Physical and Rehabilitation Medicine Practice

BACKGROUND

It has already been shown that it is feasible to use International Classification of Functioning, Disability and Health (ICF) Sets as self-assessment instruments. We used this idea to design an ICF-based screening tool to assess patients of a broadly based rehabilitation department. It was developed for the purpose of having a screening tool before taking the anamnesis, as well as for rehabilitation planning and follow-up.

METHODS AND MATERIALS

The Rehabilitation Goal Screening (ReGoS) instrument is a self-report questionnaire which was developed based on the most relevant domains from the ICF Core Sets for chronic pain and rehabilitation. The ICF categories were translated into plain language and 0-10 Likert scales were used. A retrospective analysis of routine clinical data using the ReGoS tool, Work Ability Index (WAI) and Hospital Anxiety and Depression Scale (HADS) in paper- or tablet-based form was performed.

RESULTS

The average age of the N = 1.008 respondents was 53.9 years (SD = 16.2). Of the respondents, 66% (n = 665) were female. At the time of the survey, 48.3% (n = 487) of the patients were employed. ReGoS results demonstrated that the highest restrictions on a scale from 0 to 10 were found in the areas of energy and drive (M = 5.79, SD = 2.575) and activities of daily living (M = 5.54, SD = 2.778). More than a third of the respondents rated their work ability as critical.

CONCLUSION

The use of the ReGoS instrument as an ICF-based screening tool based on a self-report questionnaire provides relevant information for clinical diagnosis, participative goal setting and a detailed functional capacity profile.

Barriers and Facilitators to Healthcare Service Access among Persons with Spinal Cord Injury (SCI)

Background

Despite having a high healthcare need, persons with complex conditions are less likely to receive comprehensive care. Individuals with SCI experience difficulties accessing services 2-4 times more than the general population. There is little agreement concerning the factors that influence these access restrictions. Few studies focus on health system impact on characteristics on access.

Objective

To outline barriers and facilitators to service access among persons with SCI across 22 countries in terms of health system characteristics

Methods

InSCI(2017): 1st community survey on experience of persons with SCI, 12591 participants, 22 countries (Australia, Brazil, China, France, Germany, Greece, Indonesia, Italy, Japan, Lithuania, Malaysia, Morocco, the Netherlands, Norway, Poland, Romania, South Africa, South Korea, Spain, Switzerland, Thailand, USA).

Data analysis

1. Hierarchical cluster analysis based on Gower distance (to group systems by access restrictions: Acceptability, Approachability, Availability, Affordability, Appropriateness).

2. Generalized linear mixed-effects decision tree (to explore the association of system characteristics and access, including WHO and OECD system indicators (e.g. UHC index, expenditure, human resources). Missing values were imputed with missforest.

Results

12% of persons with SCI reported having an access restriction, most of them (7%) with Availability. By country, the highest unmet needs were reported in Poland (25%), Germany, Lithuania, and Romania (13).

1. Cluster analysis: 7 health systems clusters (groups) were identified.

2. By June 2022, we will have the results of the second analysis: the association of system characteristics with access and how it is modified by socio-demographic and medical factors.

Expected conclusions

The study identifies factors a country could modify in order to improve access and strengthen the system for persons with SCI/disability, that might be relevant to general population as well.

Key messages

• Persons with SCI often experience similar access restrictions across countries, incl. those with high-performing health systems. System strengthening in this area is further required in all countries.

• Health systems are fragmented, e.g. healthcare quality and access inside a country differs by region, urban/rural setting etc., hence, the systems are challenging to classify.

Digitalisierung in der Rehabilitation von rheumatischen Erkrankungen: Was ist sinnvoll, was ist bewiesen, welche Perspektiven gibt es?

In Deutschland besteht ein deutlicher Mangel an internistischen Rheumatologen. Um diese Versorgungslücke zu reduzieren, können verschiedene technische Anwendungen genutzt werden. Dies reicht von der Hilfe bei der Früherkennung und Diagnostik für Hausärzte, über Konsilsysteme mit Telemedizin, bis hin zur Videosprechstunde mit den Patienten nach Koordination in einem entsprechenden Netzwerk, das stufenförmig aufgebaut ist, um die vorhandenen Spezialisten möglichst effektiv einzusetzen. Auch Apps für die Nutzung am Smartphone oder Tablet können sowohl Ärzte in Diagnostik und Therapie unterstützen, aber auch vielfältig Patienten bei den jeweiligen Krankheitsbewältigungen helfen. Eine Sonderform sind dabei „Digitale Gesundheitsanwendungen“ (DiGAs), die geprüft wurden und als Medizinprodukte zugelassen und verordnungsfähig sind. Für die Unterstützung von Bewegungsübungen, wie sie bei rheumatischen Erkrankungen so wichtig sind, kommen auch Telemedizinische Assistenzsysteme in Betracht, bei denen über 3D-Kamera und Computeranalyse zu Hause ein individuelles Übungsprogramm angeleitet und kontrolliert wird. Studien zu Anwendungen und Bewertungsoptionen für Apps liegen bereits einige vor, hier besteht aber noch hoher Nachholbedarf.

[Translation, Adaptation, Reliability and Validity of the German Version of the Prosthesis Mobility Questionnaire 2.0 (PMQ) on Patients with Major Lower Limb Amputation]

PURPOSE

The aim of this prospective validation study was to translate the Prosthesis Mobility Questionnaire 2.0 (PMQ) into German based on a guideline, following by psychometric testing for its validity and reliability using classical test theory.

METHODS

The PMQ was translated into German according to ISPOR guidelines using double forward and double backward translations, finalized by pilot testing (N=10). Subsequently, assessment of the validity and reliability was performed from March 2020 to August 2020 on N=61 patients with unilateral lower limb amputation. Construct validity was determined by using the German version of the Locomotor Capabilities Index-5 (LCI-5-D), the Rivermead Mobility Index (RMI), the Timed up and go Test (TUG), and K-levels. Cronbach's alpha was calculated to check internal consistency and discriminatory power was determined by item correlations. Test-retest reliability was calculated using ICC (2,1). Based on the ICC, the minimum detectable difference (MDC) was calculated.

RESULTS

The translation process required small changes after the pilot test. The validation study was performed on N=61 patients (56.59±13.16 years, m/f=38/23). A mean PMQ of 26.23±8.89 points was achieved. Ceilings or floor effects for total score did not appear. Construct validity showed strong positive correlations to LCI-5-D (r=0.74, p<0.001), RMI (r=0.63 p<0.001) as well as k-levels (r=0.61 p<0.001) and moderate negative correlation to TUG (r=- 0.49, p<0.001). Internal consistency was excellent with Cronbach's alpha=0.95). All items showed a value greater than r=0.40 for item-to-total score correlation. Test-retest reliability was excellent with an ICC (2,1)=0.98 with a timespan between T0 and T1 of 3.2±2.83 days. Based on this results, the MDC was 3.40 points.

CONCLUSION

The German version of the Prosthesis Mobility Questionnaire 2.0 is a valid, reliable patient reported outcome measure (PROM) for measuring mobility and functional ability of patients with exoprosthesis due to unilateral lower limb amputation. It can be used for a German-speaking population.

Which factors have an association to the Quality of Life (QoL) of people with acquired Spinal Cord Injury (SCI)? A cross-sectional explorative observational study

STUDY DESIGN

Cross-sectional explorative observational study.

OBJECTIVES

To identify factors which have an association to the self-perceived Quality of Life (QoL) for persons with acquired spinal cord injury (SCI).

SETTING

Eight specialized SCI-centers in Germany. The GerSCI survey is the German part of the International Spinal Cord Injury Survey (InSCI).

METHODS

Self-disclosure questionnaire, created from the InSCI group, translated and adapted for Germany. The questionnaire collects a very broad range of data and, and due to its design as a self-report, is particularly suitable for the analysis on QoL. Because of the content, which is binding for all participating states, it allows a direct comparability of the results. Included in Germany were 1479 persons with acquired SCI aged 18 years and older.

RESULTS

Various factors were identified with high associations to QoL, including changeable and unchangeable ones, such as those of particular importance: pain, sleep problems, sexual dysfunction, age, and time since onset of SCI. Some results confirmed reports of previous studies, others were surprising.

CONCLUSION

this study provides an important basis for the planned analysis of the InSCI participating countries in the 6 WHO regions. Germany was able to contribute the largest study population. The concrete study design of InSCI allows us to directly compare data and helps us to improve ourselves within the framework of a "learning health system". Medical measures can be orientated towards the found results, in order to ensure the best possible care and support by the therapeutic team, individually adapted to the person, place of residence and impairment.

Combination of acupuncture and medical training therapy on tension type headache: Results of a randomised controlled pilot study

OBJECTIVES

The aim of this study was to compare the effects of acupuncture and medical training therapy alone and in combination with those of usual care on the pain sensation of patients with frequent episodic and chronic tension-type headache.

DESIGN

This was a prospective single-centre randomised controlled trial with four balanced treatment arms. The allocation was carried out by pre-generated randomisation lists in the ratio 1:1:1:1 with different permutation block sizes.

SETTING

The study was undertaken in the outpatient clinic of Rehabilitation Medicine of the Hannover Medical School.Participants and interventions: Ninety-six adult patients with tension-type headache were included and randomised into usual care (n = 24), acupuncture (n = 24), medical training (n = 24), and combination of acupuncture and medical training (n = 24). One patient was excluded from analysis because of withdrawing her/his consent, leaving 95 patients for intention to treat analysis. Each therapy arm consisted of 6 weeks of treatment with 12 interventions. Follow-up was at 3 and 6 months.

MAIN OUTCOME MEASURES

Pain intensity (average, maximum and minimum), frequency of headache, responder rate (50% frequency reduction), duration of headache and use of headache medication.Clinical results: The combination of acupuncture and medical training therapy significantly reduced mean pain intensity compared to usual care (mean = -38%, standard deviation = 25%, p = 0.012). Comparable reductions were observed for maximal pain intensity (-25%, standard deviation = 20%, 0.014) and for minimal pain intensity (-35%, standard deviation = 31%, 0.03). In contrast, neither acupuncture nor medical training therapy differed significantly from usual care. No between-group differences were found in headache frequency, mean duration of headache episodes, and pain medication intake. At 3 months, the majority of all patients showed a reduction of at least 50% in headache frequency. At 6 months, significantly higher responder rates were found in all intervention groups compared to usual care.

CONCLUSIONS

In contrast to monotherapy, only the combination of acupuncture and medical training therapy was significantly superior in reduction of pain intensity compared to usual care.Trial registration: Registered on 11 February 2019. German Clinical Trials Register, DRKS00016723.

"Fit for work and life": an innovative concept to improve health and work ability of employees, integrating prevention, therapy and rehabilitation

OBJECTIVES

To set up a comprehensive health programme for employees, with needs-based allocation to preventive and rehabilitative measures; and to evaluate the effects of the programme on work ability and sick leave.

DESIGN

Prospective single-group observational study.

METHODS

Employees of a university hospital were invited to participate in needs-based interventions of preventive or rehabilitative character. Allocation followed screening questionnaires, anamnesis and clinical examination. The selection of a preventive or rehabilitative measure appropriate to the needs of the patient followed screening questionnaires, anamnesis and clinical examination. Preventive offers can include back training courses, water gymnastics or stress management exercises. Rehabilitative measures can include 3-6 weeks in- or outpatient rehabilitation or one week intensive outpatient rehabilitation. The main outcome parameters were work ability and sick leave duration.

RESULTS

At this time of the project included 1,547 participants, who applied voluntarily to enter the programme. The mean age of participants was 44.3 years (standard deviation (SD) 10.3 years), and 72.0% were female. Needs-based allocation to a prevention (n=1,218) or a rehabilitation group (n=329) was effective, and enabled formation of 2 groups with different needs. Overall, more than half of the employees participating in the programme reported sick leave within the last 3 months. Participants in the preventive measures group reported significantly lower duration of sick leave than those in the rehabilitation group. Employees in the rehabilitation group had significantly lower work ability (Work Ability Index (WAI) 30.4 vs 36.6), but higher effects at 6-month follow-up (WAI 33.4 (standardized effect size (SES) 0.51) vs 37.9 (SES 0.17)). In the prevention group mean sick leave reduced significantly from 1.9 to 1.3 weeks (p < 0.001) during the previous 3-month period, whereas in the rehabilitation group it reduced from 2.7 to 1.5 (p < 0.001) weeks.

CONCLUSION

Implementation of the comprehensive health programme was successful, using the multimodal infrastructure of a university hospital. Allocation to suitable interventions in occupational health programmes following screening, anamnesis and clinical examination is an appropriate way to meet participants' needs. The programme resulted in improved work ability and less sick leave.

[Spinal Cord Injury in Germany - a Survey on the Living and Care Situation of People with Spinal Cord Injury]

PURPOSE

Multiple organizations like UN and WHO call for the collection of internationally comparable data on living and supply conditions of people with disabilities. Furthermore, reliable national data are necessary for ensuring appropriate care. Regarding patients with Spinal Cord Injury (SCI) in Germany, only data on diagnostics or therapeutic interventions is currently available. The International Spinal Cord Injury Survey aims at collecting reliable data of people with SCI in 21 countries and developing recommendations for actions to be taken by policy-makers and other decision-makers.

METHODS

In 2017, eight specialized SCI-centers across Germany sent a standardized questionnaire to their patients who had diagnosis of SCI, and were older than 18 years (n=5,598). The questionnaire could be completed paper-based or online.

RESULTS

1,479 patients participated in the study and were included in data analysis. On average, participants were 55.3 years (SD=14.6) old, ¾ were male. The mean time of onset of paralysis was 13.9 years. Two thirds of the spinal cord injury causes were traumatic. In 51.2% SCI was classified as paraplegia. The most frequently cited health problem was sexual dysfunction. Medical treatment for this problem was rarely used. Serious environmental barriers were the inadequate accessibility of private households and public places. 42.5% of the respondents in working age were employed, which is 10% less than in Switzerland.

DISCUSSION

Serious problems in environmental barriers, medical care and labor market participation were identified for people with SCI. The results will be reported to and discussed with political decision makers and further actors to create solutions. This requires extensive efforts, like modification in building law and home support.

The best from East and West? Acupuncture and medical training therapy as monotherapies or in combination for adult patients with episodic and chronic tension-type headache: study protocol for a randomized controlled trial

BACKGROUND

This study aims to evaluate the feasibility and efficacy of a complex health intervention, based on the combination of conventional Western medicine and traditional Chinese medicine (TCM), in an outpatient department of a university hospital for patients with frequent episodic or chronic tension-type headaches.

METHODS/DESIGN

This is a prospective randomized controlled pilot study with four balanced treatment arms (usual care, acupuncture, training, and training plus acupuncture). Each arm will have 24 patients. After the initial screening examination and randomization, a 6-week treatment period follows, with treatment frequencies decreasing at 2-week intervals. After completion of the intervention, two follow-up evaluations will be performed 3 and 6 months after the start of treatment. At predefined times, the various outcomes (pain intensity, health-related quality of life, pain duration, autonomic regulation, and heart rate variability) as well as the participants' acceptance of the complex treatment will be evaluated with valid assessment instruments (Migraine Disability Assessment, PHQ-D, GAD-7, and SF-12) and a headache diary. The acupuncture treatment will be based on the rules of TCM, comprising a standardized combination of acupuncture points and additional points selected according to individual pain localization. The training therapy comprises a combination of strength training, endurance training, and training to improve flexibility and coordination. Besides descriptive analyses of the samples, their comparability will be assessed using an analysis of variance (ANOVA) or chi-squared tests. Analyses will be performed on an intention-to-treat basis. Potential interaction effects will be calculated using a repeated-measures ANOVA to test the primary and secondary hypotheses. In supplementary analyses, the proportion of treatment responders (those with a 50% reduction in the frequency of pain episodes) will be determined for each treatment arm.

DISCUSSION

This trial may provide evidence for the additive effects of acupuncture and medical training therapy as a combination treatment and may scientifically support the implementation of this complex health intervention.

TRIAL REGISTRATION

Registered on 11 Feburary 2019. German Clinical Trials Register, DRKS00016723.

[Factors Influencing Access to Follow-Up Rehabilitation]

PURPOSE

Identification of patient-related influencing factors on access to follow-up rehabilitation METHODS: Partially standardized, written survey of patients between the ages of 18 and 65 in 3 acute hospitals in Hanover, who were assigned to one of the following six defined indication groups on the basis of their diagnosis: (1) surgically treated bone fractures, (2) knee and hip endoprosthesis, (3) malignant disease from visceral surgery, (4) heart disease without surgical intervention, (5) heart disease with surgical intervention, and (6) stroke. In addition to personal information (such as age and gender) personal rehabilitation goals, rehabilitation motivation, disease processing, functioning, state of health, the knowledge of right to request and suffrage and the personal desire to start a follow-up rehabilitation were raised.

RESULTS

Of the 1,227 patients surveyed, 42.5% received follow-up rehabilitation. The percentages between the groups of diagnoses varied widely and were lowest after conservatively treated heart disease (3.2%) and highest after knee and hip joint replacement (98.1%). Including cases with a follow-up rehabilitation relevant diagnosis (n=1,000), the proportion of persons with rehabilitation increased to 51.7% (p<0.001). Reasons for an untreated follow-up rehabilitation were in rare cases the rejection by the payer (0.7%), the rejection by the patient (1.6%) or the lack of rehabilitation ability (3.3%). However in most cases the application remained without further differentiation (28.5%). The most important factor influencing follow-up rehabilitation access were diagnosis. Compared to knee- and hip endoprosthesis, the patients from other relevant diagnosis groups had a much lower chance to start a follow-up rehabilitation (OR from 0,01 up to 0,07; p<0,001). The desire of the patient showed the second most and significant influence to get follow-up rehabilitation (OR=8.18; p<0.001).

CONCLUSIONS

The diagnosis was identified as the most important criterion for follow-up rehabilitation access. No measurable factors of functioning seem to have a big influence. Therefore, the individual doctor's decision to submit an application is of particular importance. Especially because of the low level of medical knowledge on the indication catalog of the German pension insurance, the medical treatment based on professional experience as well as the lack of further education possibilities (Gottschling-Lang, 2016), it can be assumed that the follow-up rehabilitation is less standardized and systematic. In order to ensure a need-based patient care, assessment procedures should be established and the training and continuing education of physicians should be supplemented with the topic of follow-up rehabilitation.

Isokinetische Kraftmessung in Abhängigkeit von der attestierten Arbeitsunfähigkeit orthopädischer Rehabilitanden mit degenerativen Kniegelenkserkrankungen

Fragestellung Untersucht wurde die Veränderung des maximalen isokinetischen Drehmoments am Kniegelenk im Rehabilitationsverlauf in Abhängigkeit von der ärztlich attestierten Arbeitsunfähigkeit. Weiterhin wurde analysiert, ob es einen Einfluss der Arbeitsunfähigkeit auf die während der isokinetischen Testung ermittelten Variationskoeffizienten gibt.

Material und Methoden Für die Pilotstudie wurden männliche Rehabilitanden zwischen 18 und 65 Jahren mit chronisch degenerativen Kniegelenkserkrankungen in einem orthopädischen Rehabilitationszentrum rekrutiert. Die Patienten wurden bei Rehabilitationsaufnahme gemäß der im Rahmen der kassenärztlichen Versorgung festgestellten Arbeitsunfähigkeit in arbeitsfähige und arbeitsunfähige Patienten aufgeteilt. Die Messungen des maximalen isokinetischen Drehmoments erfolgten mittels des Geräts BIODEX am betroffenen Kniegelenk zu Beginn und Ende der Rehabilitation in Flexion und Extension bei Winkelgeschwindigkeiten von 90°/s und 150°/s.

Ergebnisse Eingeschlossen wurden 60 Patienten mit einem durchschnittlichen Alter von 49,6 Jahren. 43,3% der Patienten waren zu Rehabilitationsbeginn arbeitsunfähig. Die arbeitsfähigen Rehabilitanden verbesserten sich signifikant hinsichtlich des maximalen Drehmoments in beiden Winkelgeschwindigkeiten und Bewegungsrichtungen. Die arbeitsunfähigen Rehabilitanden verbesserten sich signifikant in Bezug auf die Flexionsbewegung beider Winkelgeschwindigkeiten. Zwischen den arbeitsfähigen und arbeitsunfähigen Rehabilitanden gab es keinen signifikanten Unterschied hinsichtlich der Kraftveränderung. Die im Rahmen der kassenärztlichen Versorgung festgestellte Arbeitsunfähigkeit hatte unter Berücksichtigung weiterer Kontrollvariablen keinen signifikanten Einfluss auf die Veränderung des maximalen Drehmoments und der Variationskoeffizienten.

Diskussion und Schlussfolgerung Im Rahmen der orthopädischen Rehabilitation verbesserten sich sowohl arbeitsfähige als auch arbeitsunfähige Rehabilitanden hinsichtlich des maximalen isokinetischen Drehmoments am betroffenen Kniegelenk, wobei die Verbesserung der arbeitsunfähigen Patienten in die Extension nicht signifikant war. Sowohl die attestierte Arbeitsunfähigkeit als auch die Variationskoeffizienten hatten keinen signifikanten Einfluss auf die isokinetische Kraftmessung. Weitere Analysen sollten sich insbesondere auf den Zusammenhang zwischen der Arbeitsunfähigkeitsdauer und der Ergebnisse funktioneller Assessments beziehen.

[Determinants for the Access to Follow-Up Rehabilitation Concerning Cardiological Patients after Surgery]

OBJECTIVE

The aim was to analyze individual and environmental factors influencing the access to follow-up rehabilitation of cardiological patients after surgery.

METHODS

An exploratory, cross-sectional study without intervention was conducted. A standardized questionnaire was used for data collection in two acute care clinics at cardiological and cardiosurgical wards. Multivariate logistic regression was used to measure the influence of different factors on the access to follow-up rehabilitation. In 61.0% of the patients a follow-up rehabilitation was granted.

RESULTS

210 patients were included. The average age was 52.1 years, 81.0% were male. There were significant differences between the groups with and without follow-up rehabilitation concerning age (p=0.018), sex (p=0.007), the PAREMO-scales "Änderungsbereitschaft" (p=0.011) and "Skepsis" (p=0.005) and the aim of rehabilitation to learn skills in dealing with the disease (p=0.043). The Barthel-Index was not significant different between the two groups. The chance to get a follow-up rehabilitation was significantly increased by indications corresponding to the "AHB-Indikationskatalog" (p=0.001; OR=5.76) and after request of the patients to get a follow-up rehabilitation (p<0.001; OR=17.91).

DISCUSSION

The access to follow-up rehabilitation was predominantly indication-specific and depended on patients' request of cardiological patients after surgery. A follow-up rehabilitation requires an adequate rehabilitation capacity (Barthel-Index). However the effect of the Barthel-Index on the access to follow-up rehabilitation was not significant.

CONCLUSION

It is still in question, to what extent the personal patient's wish can be linked to parameters of rehabilitation capacity. Furthermore it is necessary to develop concepts which increase the influence of rehabilitation capacity on the decision of a follow-up rehabilitation.

Rehabilitation Services Provision and Payment

Persons with spinal cord injury (SCI) experience disability and have significant need for rehabilitation. To deliver appropriate rehabilitation, interventions and programs suitable services must exist. A prerequisite for system improvement is a description of rehabilitation services. The aim of this paper was to develop a rehabilitation service framework for SCI. Additionally, principles and models of payment of rehabilitation services will be discussed. Health-related rehabilitation services should be available along the continuum of care and implemented at all levels of health care. The three most important types of services are acute, postacute, and long-term rehabilitation services. Health-related rehabilitation services for patients with SCI must be able to provide high-quality equipment and a well-trained, highly specialized and multiprofessional team of rehabilitation workers. The principles of payment for SCI rehabilitation services vary according to the organization of health care systems, which primarily depends on the sources of money (eg, from national health care systems, other health insurances, or out of pocket). Funding systems and payment criteria may influence service provision and justice in service delivery. It is important to analyze the provision of rehabilitation services and the related funding system using uniform assessment and evaluation tools.

Early Workplace Intervention to Improve the Work Ability of Employees with Musculoskeletal Disorders in a German University Hospital-Results of a Pilot Study

Health promotion is becoming increasingly important in work life. Healthcare workers seem to be at special risk, experiencing musculoskeletal disorders (MSD); their situation is strongly influenced by demographic changes. The aim of this study is to evaluate the feasibility and outcome of a worksite intervention. In a one-group pretest-posttest design, 118 employees of a hospital were recruited from 2010 to 2011. The raised parameters were satisfaction with the program, work ability (Work Ability Index), and sickness absence (provided by human resource management). Patient-reported questionnaire data was raised at baseline (t1) and after three months (t2). Sickness leave was evaluated in the period six months prior to and six months after the intervention. Means, frequencies, standardized effect sizes (SES), analysis of variance, and regression analysis were carried out. Participants were found to be highly satisfied. Work ability increased with moderate effects (SES = 0.34; p < 0.001) and prognosis of gainful employment (SES = −0.19; p ≤ 0.047) with small effects. Days of MSD-related sickness absence were reduced by 38.5% after six months. The worksite intervention program is transferable to a hospital setting and integration in occupational health management is recommended. The use of a control group is necessary to demonstrate the effectiveness.

[Development and Implementation of a Comprehensive Health Management System (Fit for Work and Life) for Employees of a University Hospital - A Practice Report]

Background: Due to the increase of sick leave, prolonging working life and the prediction of shortage of skilled workers in the future, health management systems are continuously gaining importance. Employees in a University Hospital are exposed to particular stress factors, which are also reflected in a higher than average amount of sick leave. Against this background, the project "Fit for Work and Life" (FWL) was developed and implemented by the Hannover Medical School (MHH). Aims: FWL aims to maintain, improve or recover the work ability of employees by offering both preventive and rehabilitative treatments. A second goal is to significantly reduce the days of sick leave. Methods: The project was jointly developed and implemented by five MHH departments and the DRV Braunschweig-Hannover (DRV BS-H) according to previously defined principles. It was scientifically evaluated by the following outcomes: average days of sick leave, work ability (WAI), quality of life (SF-36, WHOQOL), coping strategies (FERUS) and effort-reward imbalance (ERI). Results and Conclusions: So far, this project is unique in its concept. It has been successfully implemented in the organisational structures of the MHH. 376 employees have registered during the first project year. Up to now, 182 participants have completed their individual programmes. The results show that 60.4% of employees have moderate to poor WAI values. The average of the mental summary scale of the SF-36 was 44.9, indicating a high workload.

[Development of a claim form for the initiation of post-treatment rehabilitation for nationwide use by all reimbursement agencies: a report and plea for reducing administrative barriers]

We describe the results of a survey of claim forms that are used when starting rehabilitation following inpatient treatment and of an evaluation of a claim form developed on the basis of the results. The survey of different existing forms shows a high overlapping in content, suggesting the possibility of unification to one claim form that can be accepted by all insurers. In analogy to the Delphi method criteria for evaluation were consented and applied by the author group to assess the relevance of the claim forms content items for the process of initiating rehabilitation. A group of further experts added their evaluations. We prioritised the results and extracted the essential contents to conceive a unified claim form eligible for all types of rehabilitation. The claim form was discussed in 3 focus groups, revised accordingly and tested in the Hannover Medical School. Test results show that all relevant information is asked for and that the form is well manageable. The users' request for an IT-based solution and further ideas for improvement were integrated into the revised and validated version of the claim form. It is now available for all stake holders, in particular for insurers, as a means to improve quality of care and efficiency by standardisation of rehabilitation claim forms.

Constitutive activation of STAT proteins in primary lymphoid and myeloid leukemia cells and in Epstein-Barr virus (EBV)-related lymphoma cell lines

Although various molecular mechanisms of STAT protein (signal transducers and activators of transcription) activation have been identified, little is known about the functional role of STAT-dependent transcriptional activation. Herein we report the constitutive nuclear localization, phosphorylation, and DNA-binding activity of STAT proteins in leukemia cells and lymphoma cell lines. With the use of oligonucleotide probes derived from the Fc gamma RI promoter, the beta-casein promoter and a STAT-binding element in the promoter of the Bci-2 gene constitutive activation of STAT proteins was detected in untreated acute T- and C/B-leukemia cells (3 of 5 and 12 of 19 patients, respectively). Supershift analyses using Stats 1-6 specific antisera showed the constitutive DNA binding activity of Stat5 in these cells. Confocal microscopy revealed the nuclear localization of Stat5 and Western blot analyses showed tyrosine phosphorylation of Stat5 in nuclear extracts of acute leukemia cells. In contrast, peripheral blood mononuclear cells did not display constitutive STAT-DNA interaction. Further studies were performed on freshly isolated acute myeloid leukemia cells as well as on cell line derived K562, lymphoblastoid cells (LCL), and Burkitt's lymphoma cells (BL). Fluorescence microscopy, gelshift, and supershift experiments showed the nuclear localization and constitutive DNA-binding activity of Stat5 in K562 cells. Stat1 and Stat3 were constitutively activated in freshly isolated AML cells (10 of 14 patients) and in Epstein Barr virus-positive or interleukin-10 expressing permanent LCL and BL cells. Thus, these data indicate a differential pattern of STAT protein activation in lymphoid or myeloid leukemia and in lymphoma cells.