[Show abstract][Hide abstract] ABSTRACT: Arnold 1 · T. Brinkschmidt 2 · H.-R. Casser 3 · A. Diezemann 3 · I. Gralow 4 · D. Irnich 5 · U. Kaiser 6 · B. Klasen 2 · K. Klimczyk 7 · J. Lutz 8 · B. Nagel 3 · M. Pfingsten 9 · R. Sabatowski 6 · R. Schesser 7 · M. Schiltenwolf 10 · D. Seeger 9 · W. Söllner 11 1 Abteilung für Schmerztherapie, Klinikum Dachau, Dachau 2 Algesiologikum, München 3 DRK Schmerz-Zentrum Mainz, Mainz 4 Schmerzambulanz und Schmerz-Tagesklinik, Klinik für Anästhesiologie, operative Intensivmedizin und Schmerztherapie, Universitätsklinikum Münster, Münster 5 Interdisziplinäre Schmerzambulanz, Klinik für Anaesthesiologie, Klinikum der Universität München, München 6 UniversitätsSchmerzCentrum, Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Dresden 7 Interdisziplinäres Schmerzzentrum, m&i-Fachklinik Enzensberg, Hopfen am See 8 Interdisziplinäre Schmerztherapie, Zentralklinik Bad Berka, Bad Berka 9 Schmerztagesklinik und -ambulanz, Zentrum für Anaesthesiologie, Rettungs- und Intensivmedizin, Universitätsmedizin Göttingen, Göttingen 10 Bereich konservative Orthopädie, Schmerztherapie, Klinik für Orthopädie und Unfallchirurgie, Universitätsklinikum Heidelberg, Heidelberg 11 Klinik für Psychosomatische Medizin & Psychotherapie und Interdisziplinäre Schmerztagesklinik, Paracelsus Medizinische Privatuniversität, Klinikum Nürnberg, Nürnberg Multimodale Schmerztherapie für die Behandlung chronischer Schmerzsyndrome Ein Konsensuspapier der Ad-hoc-Kommission Multimodale interdisziplinäre Schmerztherapie der Deutschen Schmerzgesellschaft zu den Behandlungsinhalten Einleitung
[Show abstract][Hide abstract] ABSTRACT: Multimodal pain management is a comprehensive treatment of complex chronic pain syndromes. In addition to medical therapy various other specialized therapeutic interventions based on the biopsychosocial model of pain origin and chronic pain development, are added. During the last few years treatment centers for chronic pain have been established throughout Germany. Multimodal pain management has been included in the official catalogue of the recognized medical procedures for day clinic units as well as for inpatient pain management.In daily practice there is, however, still a lack of clarity and of consistency about the components that multimodal pain management should contain. This is the reason for the ad hoc commission on multimodal interdisciplinary pain management of the German Pain Society to propose the following position paper that has been worked out in a multilevel and interdisciplinary consensus process. The paper describes the mandatory treatment measures in the four core disciplines of multimodal pain management, pain medicine, psychotherapy, exercise therapy including physiotherapy and assistant medical professions including nurses.
[Show abstract][Hide abstract] ABSTRACT: We report on the design and implementation of a study protocol entitled Acupuncture randomised trial for post anaesthetic recovery and postoperative pain - a pilot study (ACUARP) designed to investigate the effectiveness of acupuncture therapy performed in the perioperative period on post anaesthetic recovery and postoperative pain.
[Show abstract][Hide abstract] ABSTRACT: Chronic ischemic pain in peripheral arterial disease (PAD) is a leading cause of pain in the lower extremities. A neuropathic component of chronic ischemic pain has been shown independent of coexisting diabetes. We aimed to identify a morphological correlate potentially associated with pain and sensory deficits in PAD. Forty patients with symptomatic PAD (Fontaine stages II-IV), 20 with intermittent claudication, CI), and 20 with critical limb ischemia (CLI) were enrolled; twelve volunteers served as healthy controls. All patients were examined using pain scales and questionnaires. All study participants underwent quantitative sensory testing (QST) at the distal calf and skin punch biopsy at the distal leg for determination of intraepidermal nerve fiber density (IENFD). Additionally, S100beta serum levels were measured as a potential marker for ischemic nerve damage. Neuropathic pain questionnaires revealed slightly higher scores and more pronounced pain-induced disability in CLI patients compared to CI patients. QST showed elevated thermal and mechanical detection pain thresholds as well as dynamic mechanical allodynia particularly in patients with advanced disease. IENFD was reduced in PAD compared to controls (p<0.05), more pronounced in the CLI subgroup (CLI: 1.3 ± 0.5 fibers/mm, CI: 2.9 ± 0.5 fibers/mm, controls: 5.3 ± 0.6 fibers/mm). In particular, increased mechanical and heat pain thresholds negatively correlated with lower IENFD. Mean S100beta levels were in the normal range but were higher in advanced disease. Patients with chronic ischemic pain had a reduced IENFD associated with impaired sensory functions. These findings support the concept of a neuropathic component in ischemic pain.
[Show abstract][Hide abstract] ABSTRACT: Background
Acupuncture was efficient and superior to sham acupuncture and a control group in the ACUpuncture in Seasonal Allergic Rhinitis (ACUSAR) trial. The article aims to inform about the study intervention, the underlying therapeutic ideas and clinical consequences.
Three-armed, randomized, controlled multi-center-trial with a 16-week follow-up during the SAR season in the first trial year and an 8 week follow-up during the SAR season in the following year.
Outpatient or private clinics in Germany.
422 Patients with seasonal allergic rhinitis on birch and grass pollen have been randomized to fall into 3 groups: 12 sessions of semi-standardised acupuncture plus rescue medication (RM, Cetirizine) or 12 sessions of sham acupuncture plus RM or RM alone during the initial two months of the study. Study intervention was defined in a Delphi consensus procedure including five experts from two major German acupuncture associations and three experts on trial methodology and statistics. A consensus between the need for standardisation and individualisation was defined using a semi-standardised treatment in the acupuncture group: 4 obligatory acupuncture points, ≥ 3 out of 8 facultative basic points and ≥ 3 facultative local or distant acupuncture points. Sham acupuncture consisted in superficial needling of at least 5 of 7 predefined, bilateral, distant non-acupuncture points. Needling characteristics such as point location, needling time, manipulation and achieved ‘De Qi' had to be documented after each session.
CM syndrome diagnoss reported most frequently were Wind-Cold invading the lung' and ‘Wind-Heat invading the lung' (37 % each). In the acupuncture group all basic obligatory points were used in 97 % of cases (LI 4, LI 11, LI 20, EX-HN 3 Yintang). The most frequently used basic optional acupuncture points were GB 20, LIV 3, ST 36, LU 7 and SP 6. The total number of needles used was higher in the acupuncture group (15.7 ± 2.5) compared to the sham acupuncture group (10.0 ± 1.6).
CM syndrome diagnoses and point selection in the acupuncture group of the trial corresponded to clinical experiences in CM treatment of SAR. Point location and a higher number of needles in the acupuncture group compared to the sham acupuncture group may have influenced the positive trial results.
Deutsche Zeitschrift für Akupunktur 06/2014; 57(3):6–11.
[Show abstract][Hide abstract] ABSTRACT: In a large randomised trial in patients with seasonal allergic rhinitis (SAR), acupuncture was superior compared to sham acupuncture and rescue medication. The aim of this paper is to describe the characteristics of the trial's participating physicians and to describe the trial intervention in accordance with the STRICTA (Standards for Reporting Interventions in Controlled Trials of Acupuncture) guidelines, to make details of the trial intervention more transparent to researchers and physicians.
ACUSAR (Acupuncture in Seasonal Allergic Rhinitis) was a three-armed, randomised, controlled multicentre trial. 422 SAR patients were randomised to semi-standardised acupuncture plus rescue medication (RM, cetirizine), sham acupuncture plus RM or RM alone. We sent a questionnaire to trial physicians in order to evaluate their characteristics regarding their education about and experience in providing acupuncture. During the trial, acupuncturists were asked to diagnose all of their patients according to Chinese Medicine (CM) as a basis for the semi-standardised, individualized intervention in the acupuncture group. Every acupuncture point used in this trial had to be documented after each session RESULTS: Acupuncture was administered in outpatient clinics by 46 (mean age 47 +/- 10 years; 24 female/ 22 male) conventionally-trained medical doctors (67% with postgraduate specialization such as internal or family medicine) with additional extensive acupuncture training (median 500 hours (1st quartile 350, 3rd quartile 1000 hours with 73% presenting a B-diploma in acupuncture training (350 hours)) and experience (mean 14 years in practice). The most reported traditional CM diagnosis was 'wind-cold invading the lung' (37%) and 'wind-heat invading the lung' (37%), followed by 'lung and spleen qi deficiency' (9%). The total number of needles used was higher in the acupuncture group compared to the sham acupuncture group (15.7 +/- 2.5 vs. 10.0 +/- 1.6).
The trial interventions were provided by well educated and experienced acupuncturists. The different number of needles in both intervention groups could be possibly a reason for the better clinical effect in SAR patients. For future trials it might be more appropriate to ensure that acupuncture and sham acupuncture groups should each be treated by a similar number of needles.Trial registration: ClinicalTrials.gov: NCT00610584.
BMC Complementary and Alternative Medicine 04/2014; 14(1):128. · 2.08 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Wall created the term preemptive analgesia in 1988 and in doing so set in motion a movement to prevent acute and chronic postsurgical pain. The concept of preemptive analgesia implies the administration of analgesic drugs or an intervention before a surgical procedure. A preemptive analgesic approach can comprise non-steroidal anti-inflammatory drugs (NSAID) and cyclo-oxygenase-2 inhibitors (coxibs) used to decrease the production of prostaglandins, local anesthetics (e.g. epidural) to reduce nociceptive input to the spinal cord as well as opioids, N-methyl-D-aspartate (NMDA) antagonists, antidepressants and anticonvulsants, all of which have an inhibitory influence on the central nervous system.
The aim of this article is to present the current possibilities and limits of preoperative pain therapy.
Since 2002 several meta-analyses on the effectiveness of preemptive analgesia have been published which came to varying conclusions on the supportive use of preemptive analgesia. The S3 guidelines on current perioperative pain management developed by the German Interdisciplinary Association for Pain Management (DIVS) specify the preemptive analgesic interventions found to be effective and will be discussed in detail in this article. Furthermore, the results of a current meta-analysis which follows the principle of preventive analgesia will be presented and which have not yet been considered in the S3 guidelines.
Preemptive analgesia can reduce acute postoperative pain; however, minimizing the development of chronic pain conditions can only be successful in combination with intraoperative and postoperative pain therapy as well as social and psychological support when indicated (preventive analgesia).
Reduction of chronic postoperative pain is an important medical function which is also justified from socioeconomic perspectives. Future studies should combine several procedures for perioperative pain therapy in order to do justice to the multifactorial aspects of pain chronification and should also be planned over a sufficiently long observation time period.
[Show abstract][Hide abstract] ABSTRACT: Gender differences can influence incidence and outcome of acute and chronic pain conditions. The reasons are to be found in genetic factors, hormonal effects and differences in anatomy and physiology. Furthermore differences relating to psychiatric comorbidities (i.e. depression) and psychosocial factors (roles, coping strategies) have been demonstrated. Men and women differ in the response to drugs and other treatments. They are differently affected by side effects of drugs. There is a gender bias in diagnosis and therapy. There is a need to study the influence of gender, age and race in order to optimize treatment towards a more individualized therapy. This article highlights already identified differences.
[Show abstract][Hide abstract] ABSTRACT: 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.
Der Schmerz 08/2013; 27(4):363-70. · 1.02 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: BACKGROUND: Flupirtine is an analgesic with muscle-relaxing properties that activates Kv7 potassium channels. Kv7 channels are expressed along myelinated and unmyelinated peripheral axons where their activation is expected to reduce axonal excitability and potentially contribute to flupirtine's clinical profile.Trial designTo investigate the electrical excitability of peripheral myelinated axons following orally administered flupirtine, in-vitro experiments on isolated peripheral nerve segments were combined with a randomised, double-blind, placebo-controlled, phase I clinical trial (RCT). METHODS: Threshold tracking was used to assess the electrical excitability of myelinated axons in isolated segments of human sural nerve in vitro and motoneurones to abductor pollicis brevis (APB) in situ in healthy subjects. In addition, the effect of flupirtine on ectopic action potential generation in myelinated axons was examined using ischemia of the lower arm. . RESULTS: Flupirtine (3-30 muM) shortened the relative refractory period and increased post-conditioned superexcitability in human myelinated axons in vitro. Similarly, in healthy subjects the relative refractory period of motoneurones to APB was reduced 2 hours after oral flupirtine but not following placebo. Whether this effect was due to a direct action of flupirtine on peripheral axons or temperature could not be resolved. Flupirtine (200 mg p.o.) also reduced ectopic axonal activity induced by 10 minutes of lower arm ischemia. In particular, high frequency (ca. 200 Hz) components of EMG were reduced in the post-ischemic period. Finally, visual analogue scale ratings of sensations perceived during the post-ischemic period were reduced following flupirtine (200 mg p.o.). CONCLUSIONS: Clinical doses of flupirtine reduce the excitability of peripheral myelinated axons.Trial registrationClinicalTrials registration is NCT01450865.
Journal of Translational Medicine 02/2013; 11(1):34. · 3.46 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The German Associations for Acupuncture, after achieving consensus, have unanimously approved and submitted blueprints on the projected revision of professional development in acupuncture and specialization in Chinese Medicine. Subsequently, the propositions will be quoted in full and explained.
Deutsche Zeitschrift für Akupunktur 01/2013; 56(3):35–40.
[Show abstract][Hide abstract] ABSTRACT: Geschlechtsspezifische Unterschiede können einen relevanten Einfluss auf Auftreten und Behandlungsergebnisse bei akuten und chronischen Schmerzen haben. Männliche und weibliche Patienten sind unterschiedlich häufig von spezifischen Schmerzerkrankungen betroffen. Die Ursachen hierfür sind vielfältig und in genetischen Faktoren, hormonellen Effekten und anderen anatomischen und physiologischen Gegebenheiten zu finden. Unterschiedliche Prävalenzen für psychische Komorbiditäten (z. B. Depressive Störungen) und psychosoziale Faktoren, wie Rollenverhalten oder Strategien zum Umgang mit Schmerzen spielen eine wichtige Rolle. Außerdem wurden Unterschiede bei erwünschten und unerwünschten Medikamentenwirkung, sowie bei nichtmedikamentösen Therapieverfahren nachgewiesen. In Zeiten individualisierter Medizin ist es sinnvoll, die Einflüsse von Geschlecht, Alter und Ethnie weiter zu untersuchen. In diesem Beitrag werden die bisher bekannten Unterschiede vorgestellt und mögliche Ursachen diskutiert.
[Show abstract][Hide abstract] ABSTRACT: Zusammenfassung
Nach den Empfehlungen der Nationalen VersorgungsLeitlinie „Kreuzschmerz“ sollte bei 6-wöchiger Schmerzdauer trotz leitliniengerechter Therapie bei positivem Nachweis von Risikofaktoren zur Chronifizierung ein umfassendes interdisziplinäres Assessment stattfinden, um die Indikation zu einem multimodalen Therapieprogramm zu prüfen. In diesem Beitrag werden die notwendigen Themenbereiche, die Inhalte und die beteiligten Disziplinen sowie der Umfang eines interdisziplinären schmerztherapeutischen Assessments beschrieben, die von der Ad-hoc-Kommission „Multimodale interdisziplinäre Schmerztherapie“ der Deutschen Schmerzgesellschaft e. V. erarbeitet wurden.
Der Schmerz 01/2013; 27:363-370. · 1.02 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Differences in gender can influence perioperative outcome, with men and women being differently affected by adverse events in the perioperative period. Differences relating to specific drug effects, comorbidities and outcomes after anesthesia or intensive care have been demonstrated. There is a gender bias in diagnosis and therapy. While knowledge regarding this field is still growing, certain aspects have already been integrated into clinical practice (prevention of postoperative nausea and vomiting, target-controlled infusion, male-only policy with production of blood products). There is a need to study the influence of gender, age, and race on perioperative outcome to optimize treatment and move toward more individualized therapy. This article highlights already identified differences and discusses potential underlying mechanisms.
The Thoracic and Cardiovascular Surgeon 12/2012; · 0.93 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Studies assessing the point-specific effect of acupuncture or the characteristics of acupuncture points (APs) tend to yield inconclusive results. In order to identify a possible confounding factor, we aimed to examine the variability in AP localization by means of a survey.
Attendees of the 14th ICMART (International Council of Medical Acupuncture and Related Techniques) congress as well as DÄGfA (German Medical Society of Acupuncture) lecturers and students were asked to locate and mark the APs LI 10 and TH 5 on a research assistant's arm. Identified points were transferred into a coordinate system, and the respective bivariate distribution function was calculated. Additionally, participants filled out a questionnaire about their acupuncture education and experience, the acupuncture style and point localization techniques used most frequently, and their estimation of the size of an AP.
The areas of the ellipses, theoretically containing 95% of AP localizations, varied between 44.49 and 5.18 cm(2). The largest distance between 2 identified points was 8.45 cm for LI 10 and 5.3 cm for TH 5. Apart from being trained at the same school, no other factor could be identified that determined the variability in AP localization.
Our results indicate that congruity of AP localization among experienced acupuncturists might be low. Although there are some limitations to our results, this possible bias should be taken into account when conducting acupuncture trials and interpreting results of previous acupuncture studies.
Forschende Komplementärmedizin / Research in Complementary Medicine 11/2012; 19(1):31-7. · 1.65 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: 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.
[Show abstract][Hide abstract] ABSTRACT: One theory about acupuncture suggests that pathological processes can cause measurable changes in electrical skin resistance (ESR) at acupuncture points (APs). Although the theory has yet to be proven, ESR measurements (ESRMs) form a frequently used part of contemporary acupuncture. The aim of this study was to test the so-called 'electrical responsiveness' of APs in the setting of a defined operative trauma.
ESRMs (n=424) were performed at the APs and surrounding skin of GB34 and ST38 in 163 participants using an impedance meter array developed for the purpose of ESRMs. For each group the percentage of measurements with a significantly different ESR between the APs and the surrounding skin was calculated and compared with each other. Measurements of four groups were compared: healthy control subjects (n=30) and patients after ophthalmic (n=29), hip (n=42) and shoulder (n=30) surgery. The influence of postoperative pain intensity was also assessed.
Group comparison showed no significant differences for ST38. The ESRMs at GB34 had a significantly higher percentage of measurements with an increased ESR after ophthalmic (23.2%) and hip (22.2%) surgery, but not after shoulder surgery (7.5%). Subgroup analysis showed that an increase in pain intensity tended to lead to a decrease in the number of APs with ESR changes.
These results suggest that reactive changes in ESR at APs might exist. Pain and alertness seem to have an impact on ESR at APs. However, the current data do not allow for conclusions to be drawn concerning the clinical use of ESRMs.
Acupuncture in Medicine 05/2012; 30(2):120-6. · 1.05 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Gender differences can have a relevant influence on the perioperative outcome as male and female patients are affected differently by adverse events, e.g. side effects of drugs. Furthermore, differences relating to specific drug effects, comorbidities and outcome after anesthesia or intensive care have been demonstrated. There seems to be a gender bias in diagnosis and therapy. While the knowledge regarding this field is still growing certain aspects have already been integrated into clinical practice: prevention of postoperative nausea and vomiting (PONV), target controlled infusion (TCI) model and male only policy with production of blood products. There is a need to study the influence of gender, age and race in order to optimize treatment towards a more individualized therapy. This article highlights already identified differences and discusses potential underlying mechanisms.
Der Anaesthesist 04/2012; 61(4):288-98. · 0.85 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Quantitative sensory testing (QST) has become a widely used method to evaluate different submodalities of the somatic sensory system (predominantly) in patients with neuropathic pain. QST consists of 7 tests measuring 13 parameters in order to assess and quantify the perception of temperature, touch, pain, pressure, and vibration. The German Research Network on Neuropathic Pain implemented a standardized QST protocol including a defined testing order of the measurements. Accordingly, subjects tested with QST undergo thermal before mechanical testing. In the present study, we investigated the effect of testing order on the results of QST. Twenty healthy subjects were tested twice, 1 week apart with 2 different QST testing orders: the standardized testing order according to the German Research Network on Neuropathic Pain and a modified testing order in which mechanical stimuli were applied before thermal stimuli. For the test protocol that began with thermal testing, subjects exhibited signs of an increased mechanical perception: The mechanical pain sensitivity was significantly increased (P = .001, Wilcoxon test) for each pinprick stimulator and the mechanical pain threshold was lowered by a factor of 2 when compared with the modified testing order in which mechanical parameters were tested at the beginning of the session without prior thermal stimulation. Thermal parameters were the same for both test-order paradigms. These data indicate that preceding mild thermal stimulation might lead to a sensitization to mechanical stimuli and thus to mechanical hyperalgesia. Alternative habituation mechanisms in the modified testing order resulting from repeated pinprick stimulation at the beginning should also be debated. QST is a helpful diagnostic tool but interpretation should be done with consideration of interaction between test parameters. Reference data are only valid in the testing order from which they are obtained. PERSPECTIVE: Present data showed that mechanical hyperalgesia followed thermal testing. This article demonstrates that the test order of quantitative sensory testing is relevant in interpreting the results obtained. Reference values are suitable in the test order from which they are obtained.
The journal of pain: official journal of the American Pain Society 01/2012; 13(1):73-80. · 3.78 Impact Factor