O. Mittag

Psychological Interventions in the Rehabilitation of Patients with Chronic Low Back Pain: Evidence and Recommendations from Systematic Reviews and Guidelines.

The purpose of the article is to summarize evidence and recommendations for psychological interventions in the rehabilitation of patients with chronic low back pain. We carried out a systematic literature search in several databases and on the websites of professional associations to identify relevant reviews and guidelines. In addition to the electronic search, a handsearch was carried out. Eligible publications were selected. We extracted and summarized both evidence for psychological interventions and recommendations on psychological diagnostics and interventions. Six systematic reviews and 14 guidelines were included. We collected recommendations and partially restricted evidence on the following psychological interventions: behavioural therapy, fear-avoidance training, stress management, relaxation therapy, patient education and back school. Most available evidence for psychological interventions in the rehabilitation of patients with chronic low back pain is of moderate to low quality. In addition, some of the older evidence is inapplicable to modern interventions using a biopsychosocial approach. Thus, high quality and current evidence is needed. The summary of guidelines shows that multimodal, multidisciplinary programmes including psychological interventions have become standard in the rehabilitation of patients with chronic low back pain. In most guidelines, however, there are no recommendations on which (psychological) intervention should be considered for which specific problem (problem–treatment pairs). Suggestions for future research and future guidelines are made.

[Systematic literature analysis on therapies applied in rehabilitation of hip and knee arthroplasty: methods, results and challenges].

Evidence-based medicine is a central issue in medical practice. This also applies to rehabilitation services. The German Statutory Pension Insurance meets this need in its guideline programme. Amongst others a guideline for rehabilitation following hip or knee arthroplasty is currently being developed. In this context a hierarchic, systematic literature analysis was conducted summarising the current state of evidence with reference to the effects and the treatment requirements (frequency and duration) of different rehabilitative therapies following total hip or knee replacement. In the first step, a search for evidence-based guidelines, systematic reviews and health technology assessments was conducted. Secondly, search strategies for primary literature in the following databases were designed: Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, and PsychINFO (01/1997-09/2007). Additionally, a handsearch of several German journals not listed in the databases was conducted. Randomized trials were preferred, however, non-randomized trials were included if the intervention and control groups were comparable with regard to the baseline parameters. Results can be classified into three categories: (1) therapies for which evidence for (positive) effects was found, (2) therapies for which evidence was found, however, their transferability onto rehabilitation in Germany should be discussed (e. g., studies on immediate post-surgery interventions), and (3) therapies for which no methodologically appropriate trials could be found. The literature reviewed does not allow for final conclusions as to frequency and duration of different therapeutic interventions within the rehabilitation time frame in Germany (usually the first three weeks post discharge from hospital). Overall, there is a need for further research.

Trajectories of depression in adults with newly diagnosed type 1 diabetes: results from the German Multicenter Diabetes Cohort Study

Aims/hypothesisThere is a paucity of longitudinal data on type 1 diabetes and depression, especially in adults. The present study prospectively analysed trajectories of depressive symptoms in adults during the first 5xa0years of living with type 1 diabetes. We aimed to identify distinct trajectories of depressive symptoms and to examine how they affect diabetes outcome.MethodsWe reanalysed data from a prospective multicentre observational cohort study including 313 adults with newly diagnosed type 1 diabetes. At baseline and in annual postal surveys over 5 consecutive years, we gathered patient characteristics and behavioural and psychosocial data (e.g. Symptom Checklist-90-R [SCL-90-R]). Medical data (e.g. HbA1c levels) was obtained from the treating physicians. We applied growth mixture modelling (GMM) to identify distinct trajectories of depression over time.ResultsFive years after diagnosis, 7.8% (nu2009=u200920) of patients were moderately depressed and 10.2% (nu2009=u200926) were severely depressed. GMM statistics identified three possible models of trajectories (class 1, ‘no depressive symptoms’; class 2, ‘worsening depressive symptoms that improve after 2xa0years’; class 3, ‘worsening depressive symptoms’). Severity of depression symptoms at baseline (subscale of the SCL-90-R questionnaire) significantly predicted membership of classes 2 and 3 vs class 1. After 5xa0years, higher HbA1c values were detected in class 3 patients (meanu2009=u20098.2%, 66xa0mmol/mol) compared with class 1 and class 2 (both: meanu2009=u20097.2%, 55xa0mmol/mol).Conclusions/interpretationWe identified distinct trajectories of depressive symptoms that are also relevant for diabetes outcome. Patients with worsening depressive symptoms over time exhibited poor glycaemic control after the first 5xa0years of living with diabetes. They also exhibited a reduced quality of life and increased diabetes-related distress.

Ergebnisse einer Analyse der therapeutischen Leistungsdaten (KTL-Daten) von 5 838 Rehabilitandinnen und Rehabilitanden nach Hüft- bzw. Knieendoprothesenimplantation

In the framework of the Practice Guidelines programme of the German Federal Pension Insurance (DRV Bund) evidence-based standards for rehabilitation following total hip or knee replacement are to be developed. The results of a quantitative analysis of present health-care on the basis of documented treatments (KTL) from 5 838 rehab patients are reported here. Based on a systematic review of international trials, treatment modules were specified and analyzed as to frequency and duration of current treatment. Furthermore, separate analyses were conducted for gender, age, and different clinics. No differences were found among rehab facilities as to exercise therapy, physiotherapy, or health education. However, psychological treatment and specific trainings differed considerably between centres.

Can trajectories of glycemic control be predicted by depression, anxiety, or diabetes-related distress in a prospective cohort of adults with newly diagnosed type 1 diabetes? Results of a five-year follow-up from the German multicenter diabetes cohort study (GMDC-Study)

AIMSnThe longitudinal association between glycemic control with depression, anxiety or diabetes-related distress in type 1 diabetes is poorly understood. Therefore, we examined long-term trajectories of HbA1c in a new-onset cohort of adults with type 1 diabetes, and analyzed associations with depression, anxiety, and diabetes-related distress.nnnMETHODSnWe included 313 newly diagnosed adults with type 1 diabetes in a prospective multicenter cohort study. Depression, anxiety, and diabetes-related distress were assessed starting with the diabetes diagnosis and at five annual surveys. HbA1c-measurements started with the one-year follow-up. HbA1c trajectories were analyzed applying Growth mixture modeling, while prediction of membership in the trajectories classes was analyzed using multiple regression, and one-way ANOVA/Chi2 to identify differences between classes.nnnRESULTSnAverage HbA1c increased constantly: follow-up at 1-year 6.5% (48u202fmmol/mol), 2-years 6.9% (52u202fmmol/mol), 3-years 7.1% (54u202fmmol/mol), 4-years 7.1% (54u202fmmol/mol), and 5-years 7.4% (57u202fmmol/mol). HbA1c trajectories included one good control and three poor control (52% of patients) classes. At the five-year follow-up, mean HbA1c was 6.3% (45u202fmmol/mol) in the good control class, and ranging from 7.9% (63u202fmmol/mol) to 9.0% (75u202fmmol/mol) in the three poor control classes. Classes were neither predicable, nor differentiated by depression, anxiety, or diabetes-related distress.nnnCONCLUSIONSnWe identified distinct trajectories of glycemic control. Depression and anxiety were highly prevalent but they neither predicted poor/good glycemic control trajectories nor were they associated with glycemic control at any assessment point.

Development of practice guidelines for psychological interventions in the rehabilitation of patients with oncological disease (breast, prostate, or colorectal cancer): Methods and results

The goal of this project was to develop evidence‐ and consensus‐based practice guidelines for psychological interventions in the rehabilitation of patients with oncological disease (breast, prostate, or colorectal cancer).

Strukturen und Praxis der psychologischen Abteilungen in der onkologischen und diabetologischen Rehabilitation: Ergebnisse einer bundesweiten Befragung

OBJECTIVEnTo study the structural frame conditions and the contents of psychological activity in oncological rehabilitation as well as in rehabilitation of patients with type 2 diabetes.nnnMETHODSnWe conducted a nationwide survey of psychological services in rehabilitation facilities treating oncological patients and patients with type 2 diabetes.nnnRESULTSn71 (of 145) oncological and 21 (of 63) diabetological rehabilitation facilities participated in the survey. In both indication areas an average of 1.1 psychologists is in charge of 100 patients. Between some rehabilitation facilities, however, there are considerable differences concerning the psychologist/patient ratio (in oncological rehabilitation facilities: standard deviation (SD)=0.52; in diabetological rehabilitation facilities: SD=0.35). Moreover, there is large heterogeneity among rehabilitation facilities as to the percentages of patients obtaining psychological interventions and the way in which psychological services allocate their working time.nnnCONCLUSIONnThe general set-up of psychological services in oncological and diabetological rehabilitation facilities (especially the low psychologist/patient ratio in many facilities) can partly be considered insufficient. The heterogeneity with respect to the structural frame conditions and practice of psychological services reveals the low degree of standardization of psychological activity in both indication areas.

Telephone-delivered lifestyle support with action planning and motivational interviewing techniques to improve rehabilitation outcomes.

Objective: In this randomized controlled trial, we evaluated the effectiveness of a telephone-delivered intervention based on the Health Action Process Approach (HAPA) after discharge from inpatient rehabilitation to address behavior change, emotional status, and glycemic control in patients with Type 2 diabetes. Design: In a German rehabilitation center, 249 patients with Type 2 diabetes were separated into randomized groups, either a 12-month telephone follow-up support group or the usual care group. The counselor identified personal target areas and intervention modules and developed with the patient an individualized action plan for the telephone support. To enhance motivational processes, they used motivational interviewing techniques. Counselors called patients monthly to support the implementation of the personal plans into the patients’ daily routines and to screen for emotional problems. Assessments measured exercise, diet, medication adherence, psychological variables, body mass index, HbA1c, and cardiovascular risk. Results: Twelve months after inpatient rehabilitation, the telephone group’s rate of physical activity rose by 26% compared with the usual care group’s 10%. Patients in the intervention group exhibited greater improvements in terms of their illness burden, psychological well-being, and depression. HbA1c fell in the telephone group but increased in the usual care group (−0.68% vs. 0.12%). The intervention group’s cardiovascular risk fell, whereas the usual care group’s rose (−0.57 vs. 0.23). Conclusion: A theory-based telephone-delivered follow-up intervention utilizing motivational interviewing techniques and focusing on personalized action planning demonstrated improvements in patients’ level of activity and health status 12-months postrehabilitation discharge and may be a beneficial supplement to rehabilitation programs.

Proaktives Screening nach Rehabilitationsbedarf bei Typ-2-Diabetikern im Disease-Management-Programm einer AOK: Welche Patienten können identifiziert werden?

BACKGROUNDnMedical rehabilitation seems suitable for implementing multimodal interventions for the treatment of type 2 diabetes. Rehabilitation in Germany on principle requires that insurees file an application. Proactive screening for rehabilitation need has only been explored in pilot projects so far. It seems a promising attempt to assess rehab need by questionnaire especially in patients with type 2 diabetes. We do not know though how patients who have been screened positive for rehab need differ from other patients with type 2 diabetes as to their health and risk profiles. This could provide an indication of the validity of the proactive approach.nnnMETHODSnMembers of an Allgemeine Ortskrankenkasse (AOK) Disease Management Program (DMP) for type 2 diabetes were screened for rehab need by questionnaire. 13 diabetes-specific problem areas were assessed. Problems were assigned to 10 specific treatments (problem-treatment-pairs). Rehab need was presumed if patients needed 3 or more treatments. Patients were then compared to regular rehab patients as well as patients with type 2 diabetes from primary care medical offices.nnnRESULTSnFrom 5500 DMP-patients 829 returned the questionnaire (return rate: 15.5%). From these 94% met the criteria for rehab need; of these 55% needed 6 or more treatments (complex problems). Patients who screened positive for rehab suffered from more health problems and had worse risk profiles as compared to patients from medical offices, and disease burden was comparable or worse as compared to regular rehab patients.nnnCONCLUSIONSnThis indicates that proactive screening for rehab need in patients with type 2 diabetes leads to reasonable (valid) results. The very low return rate suggests that the sample may be considerably biased, though. Possibly, mainly patients with greater impairment to health responded to the screening.