[Implementation of interdisciplinary multimodal pain therapy according to OPS 8‑918 : Recommendations of the ad hoc commission for interdisciplinary multimodal pain therapy of the German Pain Association]

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

[Anonymize or personalize? : Does social desirability influence the response behavior of chronic pain patients?]

BACKGROUND

The subjective state of health with respect to pain and psyche was surveyed utilizing validated pain questionnaires in patients undergoing special pain therapy and represents the basis for targeted treatment measures.

OBJECTIVE

The purpose of this study was to investigate the possible distortion of answers due to social desirability of responses in chronic pain patients.

MATERIAL AND METHODS

During two survey periods assessing patient satisfaction using both anonymized and personalized questionnaires, the effects arising from socially desirable response patterns were analyzed. The sample consisted of chronic pain patients being treated in an inpatient therapy setting.

RESULTS

In both periods of observation no significant impact on the response behavior of chronic pain patients was found in personalized or anonymized questionnaires.

CONCLUSION

The results of the study suggest that the responses of chronic pain patients with respect to their subjective state of health are not influenced by social desirability. Thus, scoring systems such as the German pain questionnaire will not be influenced by social desirability in chronic pain patients and can therefore be used as a part of diagnostics and therapy planning.

[Acute inpatient multimodal pain therapy and rehabilitation: Framework conditions, tasks and differentiated patient allocation]

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

[The arduous route of a 33-year-old woman with headache]

This article presents the case of a 33-year-old female patient with exacerbation of a pre-existing tension type headache. The exacerbation occurred within the scope of an infection and persisted after the infection had receded. The excessive diagnostic approaches went on for weeks and only finally came to an end with the diagnosis of a pregnancy. The impacts of hormonal changes on headaches caused by pregnancy are discussed as well as postinfection events.

[Multidisciplinary assessment for multimodal pain therapy. Indications and range of performance]

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

[Structure and process quality of multimodal pain therapy. Results of a survey of pain therapy clinics]

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

[Multimodal pain therapy: principles and indications]

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

[Case report on a patient with SUNCT-syndrome]

Case report on a patient with SUNCT-syndrome (short lasting, unilateral neuralgiform headache attacks with conjunctival injection, sweating, and rhinorrhoea) who was successfully treated with gabapentin. SUNCT, a still relatively unknown headache syndrome, is characterized by attacks of periorbital pain with accompanying ipsilateral autonomic symptoms. Along with this case report the differences of SUNCT to similar headaches are emphasized. Due to clear diagnostic criteria the inclusion of SUNCT in the IHS classification (International Headache Society) as a separate clinical entity should be favoured.

[Brainstem anesthesia with respiratory arrest after retrobulbar block--a case report with a review of literature]

BACKGROUND

This case shows the time course and typical clinical features of brain stem anaesthesia. It is presumed that it follows accidental injection of local anaesthetic into the subarachnoidal space via the optic nerve sheaths.

HISTORY AND SIGNS

We report the case of a 70-year-old man, who became unconscious shortly after retrobulbar anaesthesia. The first symptoms developed after an interval of several minutes following the injection of the local anaesthetic. After the appearance of cranial nerves deficits the patient complained of difficulty breathing and became unconscious and apnoeic.

THERAPY AND OUTCOME

It was decided to intubate the patient. Heart rate and systolic blood pressure dropped, therefore, a central line was placed and intravenous fluids were given. The patient was brought to the intensive care unit where he was extubated uneventfully the same day.

CONCLUSIONS

The quick clinical recovery of the patient without any sequelae and the unremarkable results of internal and neurological examines support the diagnosis of brain stem anaesthesia.

The association of hyperlipoproteinemia with dysimmunoglobulinemia

In a study of the immunoglobulin concentrations in an urban population and in patients with hyperlipoproteinemia we observed significant positive correlations between serum triglycerides and IgA independent of sex, age and body weight. In men serum triglycerides also correlated with IgG and IgM, and serum cholesterol with IgA. The prevalence of hyper- and hypoimmunoglobulinemia was significantly higher in hyperlipidemic than in normolipemic subjects. We propose that the occurrence of hyperlipoproteinemia with hypoimmunoglobulinemia may be caused by different pathobiological mechanisms than the occurrence with hyperimmunoglobulinemia.