Eva Blozik

Depression and anxiety as major determinants of neck pain: a cross-sectional study in general practice

BackgroundAlthough psychosocial factors are known to be highly linked with neck pain, current therapies focus on somatically based interventions such as medicinal or manipulatory therapies. This study examines how socio-demographic, psychosocial and medical history and health-promoting lifestyle factors interact with neck pain in general practice patients.MethodsThis is a cross-sectional survey including 448 patients from a general practice setting in Germany. Participants completed a comprehensive questionnaire including the Neck Pain and Disability Scale German version (NPAD-d) and the Hospital Anxiety and Depression Scale. Crude and adjusted regression analyses were done to assess the relationship between neck pain and socio-demographic, psychosocial and medical history and health-promoting lifestyle factors.ResultsBoth in crude and adjusted regression analyses, depression and anxiety were highly significantly linked with increasing levels of neck pain. Educational level, deficits in social support and physical exercise were associated with neck pain in bivariate analyses, but these associations did not persist with adjustment for depression and anxiety. When investigating levels of depression and anxiety by NPAD-d quartile subgroups, those who were identified to have depressive mood or to be anxious were very likely to be in the group with the highest levels of neck pain.ConclusionThe higher the neck pain level, the more attention should be paid to psychosocial distress as a related burden. Further research is needed to elucidate the causality and the direction of the association between psychosocial distress and neck pain and to determine the benefit of psychosocial interventions.

Psychometric properties of a German version of the neck pain and disability scale

The aim of this study is to evaluate the validity and the psychometric properties of a German version of the 20-item neck pain and disability scale (NPAD) for use in primary care settings. Four hundred and forty-eight participants from 15 general practices in the area of Göttingen Germany completed a multidimensional questionnaire including a newly developed German version of the NPAD (NPAD-d) and self-reported demographic and clinical information. Reliability was tested using Cronbach’s alpha. Item-to-total score correlations were analysed. Factor structure was explored by using unrestricted principal factor analysis. Construct validity of the NPAD-d was evaluated by simple correlation analyses (Pearson’s rho) with social and clinical characteristics. The discriminative abilities of the NPAD-d were examined by comparing differences between subgroups stratified on non-NPAD-d pain related characteristics using t tests for mean scores. Cronbach’s alpha of NPAD-d was 0.94. Item-to-total scale correlations ranged between 0.414 and 0.829. Exploratory principal factor analysis indicated that the NPAD-d covers one factor with an explained variance of 48%. Correlation analysis showed high correlations with criterion variables. The NAPD-d scores of subgroups of patients were significantly different showing good discriminative validity of the scale. The NPAD-d demonstrated good validity and reliability in this general practice setting. The NPAD-d may be useful in the clinical assessment process and the management of neck pain.

Skin Replacement Therapies for Diabetic Foot Ulcers : Systematic review and meta-analysis

Diabetic ulcer complications are a leading cause of hospitalization and amputation. Of the 20 million individuals with diabetes, 10–15% are at risk for developing diabetic ulcers. Standard therapy involves the use of dressings to protect the wound bed from trauma and to absorb exsudate; offloading high pressure from the wound bed, e.g., by prescribing protective footwear; and wound bed preparation to accelerate endogenous healing and facilitate the effectiveness of topically applied substances. But these measures are often deficient in healing all diabetic ulcers when the patients own intrinsic wound-healing system is insufficient. In such patients, skin replacement therapies are second-line treatment options; however, the effectiveness of skin replacement therapies in treatment of diabetic ulcers is unclear. The objective of this study is to assess their effectiveness using evidence from randomized trials in diabetic leg and foot ulceration.nnWe searched the Cochrane Controlled Trials Register (1970–2006), MEDLINE (1966–2006), EMBASE (1980–2006), and CINAHL (1982–2006) using a combination of text and keywords in addition to a filter for controlled clinical trials. The last update of searches was performed on 30 September 2007. We included trials if the allocation of participants was described as randomized, with participants of any age and in any care setting having diabetic leg or foot ulceration. We included studies that compared the following types of grafts with any other intervention: 1 ) autografts (pinch, split or full-thickness skin grafts, cultured keratinocytes, or fibroblasts), 2 ) allografts (cultured keratinocytes or fibroblasts), 3 ) xerografts, and 4 ) bioengineered skin.nnTwo reviewers independently evaluated …

Involving patients in quality indicator development - a systematic review.

Background Quality indicators (QI) are used in many health care areas to measure, compare, and improve the quality of care. Ideas of quality differ between health care providers and patients, yet patients are not regularly involved in QI development nor does a methodological standard for patient involvement in QI development exist. In this study we systematically reviewed the medical journal articles and gray literature for published approaches for involving patients in QI development. Methods We searched medical literature databases (Medline, Excerpta Medica database, and Cumulative Index to Nursing and Allied Health Literature), screened websites, and contacted experts in the field of QI development for publications on approaches to patient involvement in QI development. Results Eleven relevant journal articles and four web-published documents were included. Four major approaches to patient involvement were extracted from the literature: (1) focus group interviews, (2) self-administered questionnaires, (3) individual interviews, and (4) participation in panels during systematic consensus processes. Patients’ views were collected by involving patients, patient representatives, or family members. Conclusion Although there is a large body of literature on QI, publications that describe approaches to patient involvement in QI development are scarce. In principle, indirect and direct methods of patient involvement can be distinguished, and it seems most promising to combine different approaches. However, the limited number of publications identified clearly shows that further research in this field is overdue and that the quality of reporting found in studies within this field needs to be improved.

The experience and management of neck pain in general practice: the patients’ perspective

The objective of this study is to investigate the perspective and expectation of patients presenting with neck pain in general practice. The study design is a qualitative analysis of patient interviews and was conducted in a primary care setting in Germany. Twenty patients aged 20–78, according to theoretical sampling were included in the study. Patients tried to cope autonomously with the situation and consulted GPs only if their self-help had failed. When patients asked for external help, they usually focused on somatic treatment options such as massage, physiotherapy or injections. Most patients reported to have experiences with somatic therapies; however, they felt that some or all of these treatments were inefficient or led only to short-time improvements. Patients often avoided psychosocial themes when talking to doctors for fear of being branded as ‘neurotic’. Although neck pain is difficult to manage and a burden for patients, they have obviously found a way of both living with their pain and a pragmatic approach of talking about their symptoms with their doctor. According to the patients’ statements, the interaction between doctor and patient seems to be rather distant, ensuring that both sides avoid any issues that might touch upon psychological aspects of neck pain.

Sensitivity to change of the Neck Pain and Disability Scale

The Neck Pain and Disability Scale (NPAD) is a 20-item instrument to measure neck pain and related disability. The aim of this study was to assess sensitivity to change of the NPAD. A total of 411 participants from 15 general practices in the middle of Germany completed a multidimensional questionnaire including the German version of the NPAD and self-reported demographic and clinical information. Sensitivity to change was analysed by linear regression analysis of the NPAD at follow-up and educational level, age class, depression, anxiety, and deficits in social support, respectively, and by Pearson’s correlation analyses between mean change in NPAD at follow-up and mean change in prognostic markers. Those having more than basic education (regression coefficient −7.2, pxa0<xa00.001) and/or being in a younger age class (−2.9, pxa0=xa00.020) consistently reported significantly lower average NPAD scores at follow-up compared to those with basic education and/or a older age class. In contrast, those who were classified to be depressed (regression coefficient 2.1, pxa0<xa00.001), anxious (1.9, pxa0<xa00.001), or having deficits in social support (5.5, pxa0=xa00.004) reported significantly higher NPAD scores. Change in depression, anxiety, and social support scale between baseline and follow-up was significantly correlated with change in the NPAD score. Hence, these data are in the direction anticipated across all baseline factors investigated. In conclusion, the NPAD seems to be a sensitive measure for use in clinical practice and future studies of neck pain and related disability.

The professional perspective on patient involvement in the development of quality indicators: a qualitative analysis using the example of chronic heart failure in the German health care setting

Purpose There is an international consensus that quality indicators (QIs) of health care ought to represent patient-relevant aspects. Therefore, patient involvement in the development process is essential. However, there is no methodological gold standard for involving patients in QI development. The aim of this study is to explore experts’ views on the representation of patient-relevant aspects in the QI development process using the QIs developed in the context of the German National Disease Management Guideline for Heart Failure as an example. Methods Semi-structured, open telephone interviews were conducted with 15 German experts (patient representatives, physicians, researchers, and methodologists involved in guideline development or quality assessment). Interview themes were the relevance of the exemplary set of QIs for patients, as well as the legitimacy of, competence of, and collaboration with the patient representative who participated in the development process. Interviews were fully transcribed and content analyzed. Deductive categories derived from the research questions were supplemented by inductively formed categories during the review of the interview material. Results The qualitative analysis suggests a discrepancy between the guidelines’ QIs and those relevant to patients from an expert’s point of view, such as physician-patient communication and quality of counseling. Experts reported only minor communication and cooperation problems while working together in the guideline/QI development team. Concerns existed, for example, regarding the recruitment of patient representatives for diseases without self-help organizations, the financing of patient representation, and the training of patient representatives. Only few potential strategies for improving the process of patient involvement were mentioned. Conclusion Integrating the patients’ perspectives through the recruitment of a patient representative to participate in the development team was well established and broadly accepted. However, experts stated that the finally selected QIs represent only a small part of the patient-relevant aspects of medical care. According to the experts’ perceptions, the current processes provide a very limited scope for integrating the patients’ perspectives in a more extensive way. Supplementing the set of “conventional” QIs with additional, separately developed, “patient-side” QIs might help to include patient priorities in quality measurement.

Development of a short version of the Neck Pain and Disability Scale

Previous evaluations of the 20‐item Neck Pain and Disability Scale (NPAD) were indicative of excessive redundancy of the measure. The aim of this study was to develop a shortened version of the NPAD (sf‐NPAD) based on results of item‐to‐total‐score correlations and factor analysis as published by the developers of the original NPAD. Two items with the highest item‐to‐total score correlation were selected per factor subscale with the exception of one factor consisting of only one item. This resulted in the selection of 9 items for the sf‐NPAD. The sf‐NPAD was validated in a separate sample of 448 neck pain patients from 15 general practices in the area of Göttingen/Germany. Participants completed the 20‐item NPAD German version and gave additional sociodemographic and clinical information. Psychometric properties of the sf‐NPAD were evaluated using Cronbachs alpha, item‐to‐total‐score correlation, and unrestricted principal factor analysis. Construct validity was evaluated by Pearsons r with clinical characteristics. Discriminative validity was examined by comparing differences between subgroups stratified by psychosocial characteristics using t‐tests for mean scores. Cronbachs alpha of the sf‐NPAD was 0.88. Item‐to‐total‐scale correlations ranged between 0.628 and 0.815, and sf‐NPAD items homogeneously loaded on a single factor. Correlation analysis showed high correlations with criterion variables. The sf‐NPAD scores of patient subgroups were significantly different showing good discriminative validity. In conclusion, the sf‐NPAD demonstrated good validity and internal consistency in this general practice setting. The abbreviated version may facilitate applicability of the scale in clinical and research settings.

Imaging for low-back pain

436 www.thelancet.com Vol 373 February 7, 2009 Over the past decade there has been a broad consensus between diff erent scientifi c organisations worldwide on the benign self-limiting nature of (unspecifi c) low-back pain and hence the need for education of patients—to reassure patients and encourage them to continue with normal activities. Although most patients with back pain never receive any radiological diagnostics because they do not seek medical attention, there remains a large group who seek the dubious promise of imaging procedures despite contrary recommendations in evidence-based guidelines. These guidelines reveal that a focused history and physical examination can separate patients with non-specifi c low-back pain from those with radiculopathy, spinal stenosis, or other specifi c causes, and that clinicians should not routinely obtain imaging in patients with non-specifi c low-back pain. There are several reasons why radiological findings are not helpful for doctors or patients. First, awareness of physiological degenerative changes as diagnosed by immediate imaging might foster fear– avoidance beliefs in some patients and become an obstacle to recovery. Second, exposure to radiation doses in computed tomography or radiography is also an issue. Third, various epidemiological studies have shown that it is rare to find serious underlying conditions in primary care patients with low-back pain. Despite this evidence, many clinicians continue to use imaging routinely in primary care patients who do not have features that suggest a serious underlying condition. In The Lancet today, Roger Chou and colleagues present a meta-analysis of randomised trials that compared routine immediate imaging versus usual care without immediate imaging in patients with low-back pain. The results support guideline recommendations made on the basis of consistent evidence from high-quality randomised trials. Their review particularly focuses on clinically relevant outcomes, such as pain or function, quality of life, Imaging for low-back pain

Bridging the gap between patient needs and quality indicators: a qualitative study with chronic heart failure patients

Background The German National Disease Management Guideline (NDMG) on chronic heart failure (CHF) derived nine clinical quality indicators (QIs) to enable assessment of quality of health care in patients with CHF. These QIs epitomize an evidence-based and somatic point of view of guided treatment, but little is known about the experiences and views of patients with their guideline-based treatment across multiple health care sectors. Objective The purpose of this qualitative study was to explore patient perspectives on guided treatment of CHF across multiple health care sectors. Furthermore, it was investigated to what extent patient perspectives are represented by the QIs of the German NDMG. Methods Using a qualitative approach, semistructured interviews were carried out with 17 CHF patients. Interviews were audio-recorded and transcribed verbatim. Data were analyzed using qualitative content analysis. Results Patient-identified needs focused primarily on aspects like the doctor–patient relationship, communication, quality of individual-tailored information, and professional advice. Patients perceived shortcomings in processes of care such as communication and cooperation across health care sectors, especially at the transition between hospital and outpatient care. Discussion From the patient perspectives, the QIs do represent relevant somatic and clinical aims for quality measurement. However, deficits were identified, especially related to communication and cooperation across health care sectors. Given the fact that the inclusion of patient perspectives in quality improvement processes provides an important contribution to patient-centered health care, possible approaches for QI development such as direct and indirect patient involvement or generic vs disease-specific patient-related QIs should be the subject of future discussions.