Articles: function.
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Randomized Controlled Trial Clinical Trial
Multidisciplinary rehabilitation for chronic back pain in an outpatient setting: a controlled randomized trial.
Based on existing models for pain chronicity and effective treatment strategies for patients with chronic low back pain, a multidisciplinary rehabilitation programme for an outpatient group setting was developed. The main treatment components address the patient's physical functional capacity (functional restoring), cognitive and affective processes (pain management strategies), and behavioural and ergonomical aspects (back school elements). Short-term (immediately after intervention) and long-term effects (at 6-months follow-up) of the intervention were assessed in a randomized controlled study. ⋯ In contrast to post-treatment results, there were also significant improvements in strength and endurance. Overall results testify to the effectiveness of the intervention programme. Future studies (with larger sample sizes) should aim at a further improvement of functional capacity and disability perception, an analysis of differential treatment effects, and strategies for an improved long-term maintenance of the changes induced by the programme.
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In the intensive care unit (ICU) setting, the combination of mechanical ventilation and renal replacement therapy (RRT) has been associated with prolonged length of hospital stay, high cost of care and poor outcome. We gathered outcome data on patients who had severe renal dysfunction on transfer to our regional weaning center (RWC) for attempted weaning from prolonged mechanical ventilation (PMV). We screened the admission laboratory values of 1077 patients transferred to our RWC over an 8-year period. We reviewed the medical records of patients with serum creatinine > 2.5 mg/dl. ⋯ Patients who require PMV and RRT have a very poor prognosis. The small number of patients with renal insufficiency not requiring RRT had a more favorable hospital outcome and mortality, but long-term survival remained poor.
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The majority of authors agree today that psychosocial factors have more influence on a successful treatment of chronic back pain than other variables, in particular medical findings. Therefore treatments aim to integrate psychotherapeutic intervention in order to lessen emotional impairment, to change behavioral patterns (which advocate rest and the avoidance of physical activity), and to change cognitive attitudes and fears concerning exercise and work ability. Nevertheless, the interplay of cognitive measures and disability in treatment programs still remains an unclear issue. ⋯ An analysis of coping dimensions demonstrated that current cognitive measures might be too general to explain low back disability adequately. In addition, the results indicate that the use of the 'catastrophizing' factor as a separate variable is questionable, since it may simply be a symptom of depression. The relevance of coping as a sensitive parameter for change is also addressed. It is suggested that an alteration in coping strategies may be an important treatment effect, but is subject to individual prerequisites to maximize treatment response. Thus, future research must focus on the complex interactions between personality variables, environmental factors, and the coping demands posed by the specific nature of pain problems. A more lengthy evaluation of so-called 'fear-avoidance beliefs' in combination with 'disability' and coping dimensions could possibly lead to further treatment on the development of chronicity in chronic low back pain patients.
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Treatment of chronic cancer pain with strong opioids is indicated in about 60-70 % of patients. Surprisingly, these very potent analgesics are prescribed with great reservations in many countries, including Germany. The aim of our investigation was to analyse the supply of opioid analgesics to outpatients with cancer pain in the region of Hannover, which has about 1.1 million inhabitants. ⋯ Our data indicate a significant undertreatment of outpatients suffering from cancer pain. Taking into account the estimated total number of patients suffering from cancer, only 14.5 % (1988) and 19.0 % (1991) of all outpatients in need of strong opioids were supplied sufficiently with those analgesics. Comparing the results from the observation period in 1988 with the results from 1991 it becomes obvious that the situation has not changed. There are different reasons for the insufficiency of opioid treatment: many physicians as well as their patients are still afraid of the side effects of strong opioids. Therefore, it is necessary to improve education concerning this issue. The legal restrictions on the use of narcotics and their complexity are another important reason for doctors not to prescribe strong opioids. In 1993 the regulations were simplified; nevertheless, this has not led to a profound change in the attitude of the prescribing practitioners. Thus, further changes in legislation seem to be necessary so that the requirements for the prescription of strong opioids do not differ from other drugs.
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There is a great need to expand current knowledge of the various functional capacity measurements used in the rehabilitation of chronic low back pain (CLBP) patients. The literature on these patients reports that mobility, endurance, trunk strength and lifting capacity decrease during the process of chronicity. Chronically disabled patients appear to have lower functional capacity than asymptomatic persons. ⋯ Study results showed that physical capacity in disabled patients with low back pain is substantially reduced in comparison to persons who do not suffer from back pain. The only exception was in trunk flexor strength and endurance, in which measurements did not differ between the patients and the control group. However, even CLBP- patients with long-term pain and severe physical illness can successfully improve their physical condition by participating in an active treatment program. Back extensor muscle training has to be included in physical therapy. Because of loss of condition during the time after treatment, regular monitoring of patients and their home training programs is necessary. Overall, treatment of CLBP has to include physical training and psychosocial treatment to achieve satisfactory results.