Heinz-Dieter Basler

Multiple health risk behaviors in German first year university students

Multiple health risk behaviors have been identified as a problem in young adults which includes university students. The goals of this study included assessing the prevalence of major health risk behaviors in a cohort of German first year university students, analyzing the clustering of these behaviors and assessing readiness to change across multiple behaviors. A total of 1262 students from the schools of law, teaching and medicine at a German university participated in a voluntary and anonymous survey in 2005. The study assessed indicators and readiness for change regarding fruit and vegetable consumption, exercise, smoking and binge drinking as well as sociodemographic variables. Confirming the hypotheses, prevalences for risk behaviors were high; over 95% ate less than five servings of fruits and vegetables, 60% did not exercise sufficiently, 31% were current smokers and 62% reported binge drinking. Only 2% had none, 10.5% had one, 34.5% had two, 34.8% had three, and 18.2% showed all four risk behaviors. Readiness for behavior change was very low across multiple risk behavior combinations, especially for reducing binge drinking and increasing fruit and vegetable consumption. Medical students showed slightly more positive patterns than other students. The results indicate the need for addressing health behaviors in the student population of this university. If these findings can be replicated in other universities, programs that promote individual behavior change as well as changes in environmental conditions in the university environment are necessary to address this urgent problem.

Incorporation of cognitive-behavioral treatment into the medical care of chronic low back patients: a controlled randomized study in German pain treatment centers

Cognitive behavioral treatment has been incorporated into standard medical treatment procedures in German pain centers. Acceptance of the treatment by patients and outcome in terms of pain, coping, and disability was investigated. Components of the psychological treatment are education, relaxation and imagery, modifying thoughts and feelings, enhancement of pleasant activities, and training of good postural habits. The program was conducted in a group setting in accordance with a treatment manual and consists of 12 weekly 2.5-h sessions. A two-factor experiment with repeated measures on one factor was applied. Ninety-four consecutive patients with low-back pain were randomly assigned to an experimental group having a combined medical and cognitive-behavioral treatment, or to a control group with medical treatment only. Assessments were taken pre-treatment, post-treatment, and--in the treated group only--at a 6-months follow-up. At each assessment, patients kept a pain diary over a period of 4 weeks, and filled in self-report questionnaires. The sample consisted of 36 experimental and 40 control subjects at post-treatment. Experimental subjects reported less pain, better control over pain, more pleasurable activities and feelings, less avoidance and less catastrophizing. In addition, disability was reduced in terms of social roles, physical functions and mental performance. The results were maintained at follow-up. Patients who only received medical treatment showed little improvement. Data indicate that the program meets the needs of the patients and should be continued.

Effects of Two Guideline Implementation Strategies on Patient Outcomes in Primary Care : A Cluster Randomized Controlled Trial

Study Design. Cluster randomized controlled trial. Objective. To improve quality of care for patients with low back pain (LBP) a multifaceted general practitioner education alone and in combination with motivational counseling by practice nurses has been implemented in German general practices. We studied effects on functional capacity (main outcome), days in pain, physical activity, quality of life, or days of sick leave (secondary outcomes) compared with no intervention. Summary of Background Data. International research has lead to the development of the German LBP guideline for general practitioners. However, there is still doubt about the most effective implementation strategy. Although effects on process of care have been observed frequently, changes in patient outcomes are rarely seen. Methods. We recruited 1378 patients with LBP in 118 general practices, which were randomized to 1 of 3 study arms: a multifaceted guideline implementation (GI), GI plus training of practice nurses in motivational counseling (MC), and the postal dissemination of the guideline (controls, C). Data were collected (questionnaires and patient interviews) at baseline and after 6 and 12 months. Multilevel mixed effects modeling was used to adjust for clustering of data and potential confounders. Results. After 6 months, functional capacity was higher in the intervention groups with a cluster adjusted mean difference of 3.650 between the MC group and controls (95% CI = 0.320–6.979, P = 0.032) and 2.652 between the GI group and controls (95% CI = −0.704 to 6.007, P = 0.120). Intervention effects were more pronounced regarding days in pain per year with an average reduction of 16 (GI) to 17 days (MC) after 6 months (12 and 9 days after 12 months) compared with controls. Conclusion. Active implementation of the German LBP guideline results in slightly better outcomes during 6 months follow-up than its postal dissemination. Results are more distinct when practice nurses are trained in motivational counseling.

Acceptance and perceived barriers of implementing a guideline for managing low back in general practice

BackgroundImplementation of guidelines in clinical practice is difficult. In 2003, the German College of General Practitioners and Family Physicians (DEGAM) released an evidence-based guideline for the management of low back pain (LBP) in primary care. The objective of this study is to explore the acceptance of guideline content and perceived barriers to implementation.MethodsSeventy-two general practitioners (GPs) participating in quality circles within the framework of an educational intervention study for guideline implementation evaluated the LBP-guideline and its practicability with a standardised questionnaire. In addition, statements of group discussions were recorded using the metaplan technique and were incorporated in the discussion.ResultsMost GPs agree with the guideline content but believe that guideline stipulations are not congruent with patient wishes. Non-adherence to the guideline and contradictory information for patients by other professionals (e.g., GPs, orthopaedic surgeons, physiotherapists) are important barriers to guideline adherence. Almost half of the GPs have no access to recommended multimodal pain programs for patients with chronic LBP.ConclusionPromoting adherence to the LBP guideline requires more than enhancing knowledge about evidence-based management of LBP. Public education and an interdisciplinary consensus are important requirements for successful guideline implementation into daily practice. Guideline recommendations need to be adapted to the infrastructure of the health care system.Trial registrationBMBF Grant Nr. 01EM0113. FORIS (database for research projects in social science) Reg #: 20040116 [25].

Fear-avoidance beliefs, physical activity, and disability in elderly individuals with chronic low back pain and healthy controls.

ObjectiveResearch studies focussing on the fear-avoidance beliefs model (FABM) have expanded considerably during the last years, however, there has been very little research directed at the elderly. The objective of the present study was to investigate the validity of the FABM in older patients with chronic low back pain (CLBP). MethodIn a cross-sectional study, a group of elderly patients with CLBP (N=103) was compared with an age-matched group of pain-free individuals (N=59) to test the constructs inherent in the FABM. Constructs include fear avoidance beliefs (FABs), disability, disuse, and physical activity. In addition, the relationship of these constructs was also investigated in the patient group. CLBP-patients had an average age of 71.41 years (SD=5.2) and pain-free individuals of 71.19 years (SD=4.73). Individuals participated in a photographed series of physical activities adapted to the age group (Photograph Series of Daily Activities-German version for the elderly) for the assessment of FAB, in the Hannover Disability Questionnaire, in the Freiburg Physical Activity Questionnaire, and in an ultrasound measurement to evaluate lumbar flexion. In addition, they completed an activity diary for 1 week. Before computation, the physical activity measurements were converted into metabolic units that characterize energy expenditure. ResultsIn the patient group, FAB, pain intensity, and age predicted functional capacity, but not physical activity. Lumbar flexion was predicted by FAB and age. Patients were more fear-avoidant, reported more disability, and displayed less lumbar flexion than the pain-free individuals. No differences between the groups could be detected in regard to energy expenditure measured either by the questionnaire or by diary data. ConclusionsThe findings are consistent with results reported in the literature for younger age groups and confirm the assumption that the FABM is also valid for the elderly.

TTM-based counselling in physiotherapy does not contribute to an increase of adherence to activity recommendations in older adults with chronic low back pain--a randomised controlled trial.

Background The present study examines the outcome of counselling in physiotherapy based on the Transtheoretical Model (TTM) in a sample of elderly individuals with chronic low back pain.

Sex Differences in Presentation, Course, and Management of Low Back Pain in Primary Care

ObjectiveEpidemiologic surveys frequently show that women more often and are more affected by low back pain (LBP). The aim of this secondary analysis of a randomized controlled study was to explore whether presentation and course of LBP of women is different from men, and if sex affects the use of healthcare services for LBP. MethodsData from 1342 [778 (58%) women] patients presenting with LBP in 116 general practices were collected. Patients completed standardized questionnaires before and after consultation and were contacted by phone 4 weeks, 6 months, and 12 months later for standardized interviews by study nurses. Functional capacity was assessed with Hannover Functional Ability Questionnaire (HFAQ). Logistic regression models—adjusting for sociodemographic and disease-related data—were conducted to investigate the effect of sex for the use of healthcare services. ResultsWomen had on average a lower functional capacity at baseline and after 12 months. They were more likely to have recurrent or chronic LBP and to have a positive depression score. Being female was associated with a low functional capacity after 12 months (odds ratio: 1.7, 95% confidence interval: 1.2-2.3), but baseline functional capacity, chronicity, and depression were stronger predictors. In univariate analysis, women had a tendency of higher use of healthcare services. Those differences disappeared after adjustment. DiscussionOur findings confirm that women are more severely affected by LBP and have a worse prognosis. Utilization of healthcare services cannot be fully explained by female sex, but rather by a higher impairment by back pain and pain in other parts of the body characteristic of the female population.

Komorbidität, Multimedikation und Befinden bei älteren Patienten mit chronischen Schmerzen

Zusammenfassung. Mittels eines standardisierten Interviews wurden konsekutive Patienten [3 Schmerzpraxen (n=117), 2 Geriatriekliniken (n=86), 1 Schmerzklinik (n=60)] mit chronischen Schmerzen und mindestens einer weiteren Diagnose (im Durchschnitt: Diagnosen in 5 weiteren Organsystemen) im Alter von ≥65 Jahren (Durchschnittsalter: 76,29±7,40 Jahre, Anteil der Frauen: 73,3%) befragt. Insgesamt wurden 7,31±2,66 Medikamente mit einer Höchstzahl von 19 Medikamenten eingenommen. Fast 75% der Patienten gaben an, Schmerzlinderung sei am ehesten durch Schonverhalten zu erreichen. Jeder zweite Patient fühlte sich häufig traurig und niedergeschlagen. Häufigste Beschwerden waren trockener Mund, Schlafstörungen, Müdigkeit, Verstopfung und Schwindel. Die Patienten aus der Geriatrie waren durch höheres Lebensalter, höhere Schulbildung, geringere Schmerzausbreitung, -intensität und -dauer, geringere Anzahl verordneter Schmerzmedikamente, aber auch durch stärker ausgeprägte Komorbidität und stärkere funktionale Beeinträchtigung gekennzeichnet. Die Schmerzzentrumspatienten wiesen häufiger Schmerzen im Bereich von Hüfte und Becken auf, nahmen häufiger nur Stufe-I-Analgetika und gaben seltener eine regelmäßige Einnahme der Medikamente an. Sie fühlten sich am stärksten in ihren sozialen Kontakten beeinträchtigt, hatten aber die größte Hoffnung auf Besserung ihres Zustands. Abstract. Consecutive patients with a minimum age of 65 years and at least one additional diagnosis participated in a standardized interview during the initial assessments in two geriatric hospitals (n=86), a multidisciplinary pain center (n=60), and three primary care practices (n=117). The average age of the total sample was 76.29 years (SD=7.40); females constituted 73.3% of the sample. The average number of drugs consumed by the patients amounted to 7.31 (SD=2.66) with a maximum number of 19 drugs. Nearly threequarters of the patients indicated a reduction in their pain by avoiding physical activity. Every second patient often felt depressed and without energy. The most frequent symptoms were a dry mouth, sleep disorders, fatigue, constipation, and dizziness. Patients from the geriatric hospitals were older and better educated, reported fewer painful body regions, indicated lower intensity and duration of pain as well as a lower number of pain medications. On the other hand, they were characterized by a higher intensity of comorbidity and by increased functional impairment. Patients from the pain clinic suffered more frequently from pain in the hip and the pelvis. They took stage I analgesics more often and admitted more frequently to adjusting the drug consumption to changes in well-being and situational factors. They felt the highest amount of impairment in their social activities. Nevertheless, they expressed the highest confidence in future improvement.

The pain beliefs and perceptions inventory: further evidence for a 4-factor structure

&NA; This study employed the Pain Beliefs and Perceptions Inventory (PBPAI) (Williams and Thorn 1989) with a German sample (n = 193) of pain patients. The original version has 3 subscales:(1) self‐blame (S‐B),(2) perception of pain as mysterious (MYST), and(3) beliefs about the temporal stability of pain (TIME). Item statistics, factor structure, and discriminant validity are reported. Factor analysis favored a 4‐factor structure and replicated a finding by Strong et al. (1992). The TIME scale can be subdivided into 2 subscales: beliefs that pain is a constant and enduring experience (“Constancy”), and beliefs about the long‐term chronicity of pain (“Acceptance”). Constancy showed higher correlations with self‐reported psychological symptomatology (anxiety, general physical troubles, pain intensity) than did Acceptance, MYST, and S‐B.

The impact of specialist care for low back pain on health service utilization in primary care patients: A prospective cohort study

Guidelines portray low back pain (LBP) as a benign self‐limiting disease which should be managed mainly by primary care physicians. For the German health care system we analyze which factors are associated with receiving specialist care and how this affects treatment. This is a longitudinal prospective cohort study. General practitioners recruited consecutive adult patients presenting with LBP. Data on physical function, on depression, and on utilization of health services were collected at the first consultation and at follow‐up telephone interviews for a period of 12 months. Logistic regression models were calculated to investigate predictors for specialist consultations and use of specific health care services. Large proportions (57%) of the 1342 patients were seeking additional specialist care. Although patients receiving specialist care had more often chronic LBP and a positive depression score, the association was weak. A total of 623 (46%) patients received some form of imaging, 654 (49%) physiotherapy and 417 (31%) massage. Consulting a specialist remained the strongest predictor for imaging and therapeutic interventions while disease‐related and socio‐demographic factors were less important. Our results suggest that the high use of specialist care in Germany is due to the absence of a functioning primary care gate keeping system for patient selection. The high dependence of health care service utilization on providers rather than clinical factors indicates an unsystematic and probably inadequate management of LBP.