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Objectives: To examine the effects of acupuncture and therapeutic exercise alone and in combination on temporomandibular joint symptoms in tension-type headache and to evaluate the potential interaction of existing temporomandibular dysfunction on the success of headache treatment., Design: Pre-planned secondary analysis of a randomized controlled, non-blinded trial., Setting: Outpatient clinic of a German university hospital., Subjects: Ninety-six Participants with frequent episodic or chronic tension-type headache were randomized to one of four treatment groups., Interventions: Six weeks of acupuncture or therapeutic exercise either as monotherapies or in combination, or usual care. Follow-up at 3 and 6 months., Main Measures: Subjective temporomandibular dysfunction symptoms were measured using the Functional Questionnaire Masticatory Organ, and the influence of this sum score and objective initial dental examination on the efficacy of headache treatment interventions was analyzed., Results: Temporomandibular dysfunction score improved in all intervention groups at 3-month follow-up (usual care: 0.05 [SD 1.435]; acupuncture: -5 [SD 1.436]; therapeutic exercise: -4 [SD 1.798]; combination: -3 [SD 1.504]; P  = 0.03). After 6 months, only acupuncture (-6 [SD 1.736]) showed a significant improvement compared to the usual care group ( P  < 0.01). Subjective temporomandibular dysfunction symptoms had no overall influence on headache treatment., Conclusions: Only acupuncture had long-lasting positive effects on the symptoms of temporomandibular dysfunction. Significant dental findings seem to inhibit the efficacy of acupuncture for tension-type headache., Competing Interests: Declaration of conflicting interestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objectives: To compare the effects of acupuncture and medical training therapy in combination or individually with usual care on quality of life, depression, and anxiety in patients with tension-type headache., Methods: In this single-center, prospective, randomized, controlled, unblinded trial, 96 adults (38.7(+/-13.3) years of age; 75 females/20 males/one dropout) with frequent episodic or chronic tension-type headache were randomized to one of four treatment groups (n = 24). The treatment groups received six weeks of either acupuncture or medical training therapy as monotherapies or in combination (12 interventions each), or usual care. We assessed depressiveness (PHQ-9), anxiety (GAD-7), and health-related quality of life (SF-12) as secondary outcome parameters at baseline, six weeks, three months, and six months after initiation of treatment. Linear mixed models were calculated., Results: Both, acupuncture (baseline to six-weeks change scores: mean: -2(standard deviation: 2.5 points), three months: -2.4(2.4), six-months -2.7(3.6)) and the combination of acupuncture and medical training therapy (-2.7(4.9), -2.2(4.0), -2.2(4.2)) (each within-group p < .05) significantly reduced depressiveness-scores (PHQ-9) to a greater extent than medical training therapy (-0.3(2.0), -0.5(1.6), -0.9(2.6)) or usual care alone (-0.8(2.9), 0.1(2.8), 0.2(3.6)). We found similar results with anxiety scores and the physical sum scores of the SF-12. No severe adverse events occurred., Conclusions: Acupuncture and the combination of acupuncture and medical training therapy elicit positive effects on depression, anxiety, quality of life, and symptom intensity in patients with episodic and chronic tension-type headache. Acupuncture appears to play a central role in mediating the therapeutic effects, underscoring the clinical relevance of this treatment. An additive benefit of the combination of both therapies does not appear to be relevant. Trial registration: Registered on 11 February 2019. German Clinical Trials Register, DRKS00016723.

Background: It has already been shown that it is feasible to use International Classification of Functioning, Disability and Health (ICF) Sets as self-assessment instruments. We used this idea to design an ICF-based screening tool to assess patients of a broadly based rehabilitation department. It was developed for the purpose of having a screening tool before taking the anamnesis, as well as for rehabilitation planning and follow-up., Methods and Materials: The Rehabilitation Goal Screening (ReGoS) instrument is a self-report questionnaire which was developed based on the most relevant domains from the ICF Core Sets for chronic pain and rehabilitation. The ICF categories were translated into plain language and 0-10 Likert scales were used. A retrospective analysis of routine clinical data using the ReGoS tool, Work Ability Index (WAI) and Hospital Anxiety and Depression Scale (HADS) in paper- or tablet-based form was performed., Results: The average age of the N = 1.008 respondents was 53.9 years (SD = 16.2). Of the respondents, 66% ( n = 665) were female. At the time of the survey, 48.3% ( n = 487) of the patients were employed. ReGoS results demonstrated that the highest restrictions on a scale from 0 to 10 were found in the areas of energy and drive (M = 5.79, SD = 2.575) and activities of daily living (M = 5.54, SD = 2.778). More than a third of the respondents rated their work ability as critical., Conclusion: The use of the ReGoS instrument as an ICF-based screening tool based on a self-report questionnaire provides relevant information for clinical diagnosis, participative goal setting and a detailed functional capacity profile.

Study Design: Cross-sectional explorative observational study., Objectives: To identify factors which have an association to the self-perceived Quality of Life (QoL) for persons with acquired spinal cord injury (SCI)., Setting: Eight specialized SCI-centers in Germany. The GerSCI survey is the German part of the International Spinal Cord Injury Survey (InSCI)., Methods: Self-disclosure questionnaire, created from the InSCI group, translated and adapted for Germany. The questionnaire collects a very broad range of data and, and due to its design as a self-report, is particularly suitable for the analysis on QoL. Because of the content, which is binding for all participating states, it allows a direct comparability of the results. Included in Germany were 1479 persons with acquired SCI aged 18 years and older., Results: Various factors were identified with high associations to QoL, including changeable and unchangeable ones, such as those of particular importance: pain, sleep problems, sexual dysfunction, age, and time since onset of SCI. Some results confirmed reports of previous studies, others were surprising., Conclusion: this study provides an important basis for the planned analysis of the InSCI participating countries in the 6 WHO regions. Germany was able to contribute the largest study population. The concrete study design of InSCI allows us to directly compare data and helps us to improve ourselves within the framework of a "learning health system". Medical measures can be orientated towards the found results, in order to ensure the best possible care and support by the therapeutic team, individually adapted to the person, place of residence and impairment., (© 2021. The Author(s).)

Background: Distal femur and proximal tibia replacements as limb-salvage procedures with good outcome parameters for patients with tumours have been broadly described. However, the overall midterm outcome in a mixed, heterogeneous patient collective is still unclear., Patients and Methods: We retrospectively analysed 59 consecutive patients (33 for primary and 26 for revision surgery) between 1998 and 2017. Indication for implantation was tumour (n=16), periprosthetic fracture (n=14), traumatic fracture (n=14), infection (n=10), aseptic loosening (n=3), and pathological fracture (n=2). The mean follow-up duration was 3 years. Clinical functions were evaluated by Toronto Extremity Salvage Score and Knee Society Score. Knee extension and flexion force were measured., Results: The overall survival rate of arthroplasties was 59% (n=35). Major complications were observed in 36 (61%) patients. During the follow-up period, 14 (24%) patients died. We recorded periprosthetic joint infection in 21 (36%) patients, recurrence of tumour in two (3%), and aseptic implant failure in three (5%). The mean Toronto Extremity Salvage Score was 66±33, and the mean Knee Society Score was 49±30. The mean extension force on the operated side was significantly reduced at 60° and 180° compared to the healthy side (p=0.0151 and p=0.0411, respectively)., Conclusion: Distal femur and proximal tibia replacements showed limited clinical function in a heterogeneous patient collective. Indication for implantation should be considered carefully., (Copyright © 2021 International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.)

Objectives: The aim of this study was to compare the effects of acupuncture and medical training therapy alone and in combination with those of usual care on the pain sensation of patients with frequent episodic and chronic tension-type headache., Design: This was a prospective single-centre randomised controlled trial with four balanced treatment arms. The allocation was carried out by pre-generated randomisation lists in the ratio 1:1:1:1 with different permutation block sizes., Setting: The study was undertaken in the outpatient clinic of Rehabilitation Medicine of the Hannover Medical School. Participants and interventions: Ninety-six adult patients with tension-type headache were included and randomised into usual care (n = 24), acupuncture (n = 24), medical training (n = 24), and combination of acupuncture and medical training (n = 24). One patient was excluded from analysis because of withdrawing her/his consent, leaving 95 patients for intention to treat analysis. Each therapy arm consisted of 6 weeks of treatment with 12 interventions. Follow-up was at 3 and 6 months., Main Outcome Measures: Pain intensity (average, maximum and minimum), frequency of headache, responder rate (50% frequency reduction), duration of headache and use of headache medication. Clinical results: The combination of acupuncture and medical training therapy significantly reduced mean pain intensity compared to usual care (mean = -38%, standard deviation = 25%, p  = 0.012). Comparable reductions were observed for maximal pain intensity (-25%, standard deviation = 20%, 0.014) and for minimal pain intensity (-35%, standard deviation = 31%, 0.03). In contrast, neither acupuncture nor medical training therapy differed significantly from usual care. No between-group differences were found in headache frequency, mean duration of headache episodes, and pain medication intake. At 3 months, the majority of all patients showed a reduction of at least 50% in headache frequency. At 6 months, significantly higher responder rates were found in all intervention groups compared to usual care., Conclusions: In contrast to monotherapy, only the combination of acupuncture and medical training therapy was significantly superior in reduction of pain intensity compared to usual care. Trial registration: Registered on 11 February 2019. German Clinical Trials Register, DRKS00016723.

Objectives: To set up a comprehensive health programme for employees, with needs-based allocation to preventive and rehabilitative measures; and to evaluate the effects of the programme on work ability and sick leave., Design: Prospective single-group observational study., Methods: Employees of a university hospital were invited to participate in needs-based interventions of preventive or rehabilitative character. Allocation followed screening questionnaires, anamnesis and clinical examination. The selection of a preventive or rehabilitative measure appropriate to the needs of the patient followed screening questionnaires, anamnesis and clinical examination. Preventive offers can include back training courses, water gymnastics or stress management exercises. Rehabilitative measures can include 3-6 weeks in- or outpatient rehabilitation or one week intensive outpatient rehabilitation. The main outcome parameters were work ability and sick leave duration., Results: At this time of the project included 1,547 participants, who applied voluntarily to enter the programme. The mean age of participants was 44.3 years (standard deviation (SD) 10.3 years), and 72.0% were female. Needs-based allocation to a prevention (n=1,218) or a rehabilitation group (n=329) was effective, and enabled formation of 2 groups with different needs. Overall, more than half of the employees participating in the programme reported sick leave within the last 3 months. Participants in the preventive measures group reported significantly lower duration of sick leave than those in the rehabilitation group. Employees in the rehabilitation group had significantly lower work ability (Work Ability Index (WAI) 30.4 vs 36.6), but higher effects at 6-month follow-up (WAI 33.4 (standardized effect size (SES) 0.51) vs 37.9 (SES 0.17)). In the prevention group mean sick leave reduced significantly from 1.9 to 1.3 weeks (p < 0.001) during the previous 3-month period, whereas in the rehabilitation group it reduced from 2.7 to 1.5 (p < 0.001) weeks., Conclusion: Implementation of the comprehensive health programme was successful, using the multimodal infrastructure of a university hospital. Allocation to suitable interventions in occupational health programmes following screening, anamnesis and clinical examination is an appropriate way to meet participants' needs. The programme resulted in improved work ability and less sick leave.

Background and Objectives : The aetiology and pathomechanism of fibromyalgia syndrome 12 (FMS) as one of chronic pain syndromes still need to be further elucidated. Mitogen-activated protein kinase (MAPK) pathway has been proposed as a novel approach in pain management. Since the major symptom of fibromyalgia syndrome (FMS) patients is pain, it became of interest whether MAPK pathways, such as the stress-activated p38 MAPK/MK2 axis, are activated in FMS patients. Therefore, this study aimed at determining p38 MAPK/MK2 in FMS patients. Materials and Methods : Phosphorylation of MAPK-activated protein kinases 2 (MK2), a direct target of p38 MAPK, was measured in monocytes of FMS and healthy controls (HCs) to monitor the activity of this pathway. Results : The mean level of phosphorylated MK2 was fivefold higher in FMS patients as compared to HCs ( p < 0.001). Subgroup analysis revealed that antidepressants did not influence the activity of MK2 in FMS patients. Conclusions : This result indicates that the p38/MK2 pathway could be involved in the pathomechanism of FMS, could act as a clinical marker for FMS, and could be a possible target for pain management in FMS patients.

Background and Objectives : Musculoskeletal dysfunction can induce several types of chronic pain syndromes. It is of particular interest to elucidate the pathomechanism of different forms of chronic pain. It is possible that patients who have developed chronic widespread pain (CWP) may endure different pathomechanisms as compared to those who suffer from local pain (osteoarthritis, OA) and regional pain (chronic low back pain, cLBP), especially with regard to pain regulation and its related biomediators. The aim of this study was to determine the differences in pathomechanisms among these patients by measuring pain-related biomediators, particularly brain-derived neurotrophic factor (BDNF). Additionally, subpopulations of immune cells were determined in parallel. Materials and Methods : Patients and healthy subjects (HSs) were recruited (age and gender-matched). BDNF was measured from serum samples of patients and HSs and the data of body composition parameters were recorded. Additionally, both patients and HSs were asked to fill in questionnaires related to pain intensity, anxiety, and depression. Results : Our results highlight that the levels of both free and total BDNF are significantly lower in pain patients compared to HSs, with p values of 0.041 and 0.024, respectively. The number of CD3 - CD56 bright natural killer (NK) cells shows significant differences between the groups. Comparing all chronic pain patients with HSs reveals a significantly lower number of CD4 + CD8 + T cells ( p = 0.031), CD3 - CD56 bright NK cells ( p = 0.049) and CD20 + CD3 - cells ( p = 0.007). Conclusions : To conclude, it seems that a general conformity between the pathomechanisms of different chronic pain diseases exists, although there are unique findings only in specific chronic pain patients.

Background: Many patients have disabilities; it is therefore essential that medical education includes comprehensive teaching on disability and rehabilitation. In 2006 Hannover Medical School implemented an introductory course in the curriculum for medical students, on how to communicate with persons with disability and the need for rehabilitation. The course, entitled "Introduction to medicine", has the main goals of teaching the strategy and systematic approach of medicine to solving patients' problems., Methods: This paper describes the content, methods and outcomes of 1 of the 4 main themes of the "Introduction to medicine" course; the theme "Pain and disability", which is covered in the second week of the course., Results: Evaluation of the "Pain and disability" module found that students' ratings for the category "patient involvement" were very high (93%), whereas their ratings for the category "examination of student knowledge" were low. The overall rating of the module was "good" (10.8 out of 15 points), but not "very good"., Conclusion: The concept of the "Pain and disability" module is feasible and successful, even though it is scheduled early in the first year of the curriculum and approximately 350 students participate. Factors related to this success are: a mixture of teaching knowledge, supporting students' understanding, and applying communication and physical examination skills.

Background: It is still difficult for people with physical impairments to be and remain equally integrated into the labour market. For this reason, the question of occupational activity has explicitly been examined by the German Spinal Cord Injury Survey (GerSCI) in order to identify barriers and facilitators for labour market participation., Methods: Cross-sectional explorative observational study. The GerSCI survey is the German part of the International Spinal Cord Injury Survey (InSCI). Using survey data from persons recruited at eight specialised SCI-centres in Germany., Participants: 1.479 persons with Spinal Cord Injury (SCI) aged 18 years and older., Results: In a self-disclosure questionnaire, persons with SCI show themselves as a professionally well-educated and highly motivated group with most of them aiming at gainful employment and considering themselves fit for work. Many changeable and non-changeable factors have been found, which showed a high correlation with the return to work after acquired SCI., Conclusion: Education and pain belong to the most critical factors and thereby possible approaches to increase the level of employment, which is essential and highly relevant not only for earning money but also for self-confidence and social integration. SCI has many dimensions in itself; support also should be multidimensional. Study results might help to improve participation.

Objective: Fibromyalgia syndrome has been associated with familial clusters although the specific genetic predisposition is not clear. Accordingly, studies concerning genetic factors associated with this disease are important. Brain-derived neurotrophic factor (BDNF) has been shown to play a role in patients with fibromyalgia syndrome, particularly in mediating manifestations of pain and mood-related symptoms. Research on genetic factors, including genetic variations or single nucleotide polymorphisms, especially related to BDNF in fibromyalgia is very limited. Therefore, this study was aiming at determining the association of polymorphisms of BDNF, particularly rs2049046 (A>T) and rs7124442 (A>G), with body mass index (BMI) and mood-related symptoms in FMS., Results: In fibromyalgia syndrome cases, BDNF polymorphisms were associated with body mass index and anxiety score, specifically rs7124442 (A>G) (Fisher's exact test χ 2 ; p < 0.05; odds ratio (OR): 1.02) and rs2049046 (A>T) (Fisher's exact test χ 2 ; p < 0.05; OR: 0.55), respectively. Additionally, patients with fibromyalgia syndrome who have AA (95% CI (8.71, 11.63)) and AT (95% CI (9.32, 11.74)) alleles of rs2049046 showed higher score of anxiety compared to patients with TT (95% CI (3.98, 8.20) allele (ANOVA test; p < 0.01). These results suggest that BDNF polymorphisms (rs7124442 and rs2049046) are associated with body mass index and anxiety symptoms in patients with fibromyalgia syndrome.

In this sham-controlled study, 53 patients received 10 sessions of acupuncture treatment over 5 weeks to investigate the effects of acupuncture on the pain and quality of life of patients with osteoporosis. The results showed significant favorable effects of verum acupuncture on quality of life. Both interventions showed sustained and clinically relevant effects on pain., Purpose: Standard analgesic treatment is associated with adverse events in patients with osteoporosis, especially elderly and/or comorbid patients. As acupuncture has gained widespread acceptance as a complementary treatment modality with few side effects, the aim of this study was to evaluate the effects of acupuncture on the pain and quality of life of patients with osteoporosis., Methods: In total, 53 patients with vertebral compression fractures, osteoporosis-associated spinal deformities, and resultant pain were randomly allocated to the verum acupuncture with deep needling of specific points following the principles of traditional Chinese medicine (n = 29) or control acupuncture group with superficial needling of non-acupuncture points (n = 24). All patients received 10 sessions of standardized verum or control acupuncture treatment over 5 weeks. Pain (VAS score 1-100) and quality of life (QUALEFFO-41) were measured at the start of treatment (T0), before each acupuncture session (T1), and at 1 (T2) and 3 months (T3) post-treatment., Results: Both acupuncture treatments significantly reduced activity-related pain and pain at rest over time. The verum acupuncture group experienced a significantly greater reduction in mean pain intensity at rest than the control group. In the control group, quality of life improved only temporarily post-treatment (T2) and slightly declined at the end of the follow-up period (T3). In contrast, patients in the verum acupuncture group experienced continuous and significant improvements in quality of life up to 3 months after treatment (T3)., Conclusions: Both types of acupuncture were equally effective in producing sustained, clinically relevant pain relief in patients with osteoporosis. Verum acupuncture had stronger and longer-lasting effects on quality of life and pain at rest. The possible reasons for these findings include the specificity of acupuncture point selection and the performance of needle stimulation.

Objectives: Fibromyalgia syndrome (FMS) patients have multiple symptoms, including mental symptoms such as depression. Natural killer T (NKT) cells have shown to be correlated with depression. However, up to now there is no information regarding the role of CD3+CD56+NKT cells in FMS patients, especially in the intensity of mental symptoms. The present study aimed to observe the role of CD3+CD56+NKT cells level in FMS patients in relation to the intensity of depression., Methods: Ninety-six female patients who matched definition of FMS were divided into subgroups of depressions according to Hospital Anxiety and Depression Scale (HADS) score (HADS-Depression <8; 8-10; and >10). CD3+CD56+NKT cells from peripheral blood were measured by fluorescence-activated cell sorting methods., Results: ANOVA test in the subgroup of depression of FMS patient showed significant differences. Additionally, the differences were observed in HADSD <8 and >10. The use of antidepressant significantly altered the level of CD3+CD56+NKT cells. A blocking variable ANCOVA with antidepressant as covariate showed main effects in the subgroup of depression, however, the interaction of antidepressant and the subgroup of depression did not influence the level of CD3+CD56+NKT cells., Conclusions: These results suggest that CD3+CD56+NKT cells could play a role as a mediator in mental symptom such as depression in FMS patients. It seems the role of antidepressant in the mood intensity is not mediated by CD3+CD56+NKT cells in FMS patients. Additionally, subgrouping FMS patients based on the intensity of mental symptoms may help to optimise the treatments.

Purpose: Systematic collaboration between occupational physicians (OPs) and rehabilitation physicians (RPs) can improve occupational rehabilitation processes and outcomes. The JobReha discharge letter (JR-DL) is a key element of JobReha, a multilevel intervention for specific occupational rehabilitation of workers with musculoskeletal disorders. This feasibility study aims to analyse the perceived benefit and acceptance of the JR-DL as an instrument for improving the communication interface between RPs and OPs., Methods: On the day of discharge from rehabilitation, the rehabilitation physician completed a JR-DL form containing relevant information on the rehabilitation measures undertaken during treatment and recommendations for return to work. The JR-DL was either transmitted to the patient's occupational physician directly or given to the patients to bring to the OP to support the reintegration process. The JR-DL as an instrument for improving the communication interface was evaluated using data from patient questionnaires (n = 250), JR-DLs (n = 247), OP questionnaires (n = 224) and RP questionnaires (n = 232)., Results: All rehabilitation physicians sent a JR-DL to the respective occupational physician on the day of discharge. OPs received the reports a median 2 days after discharge. The content quality and relevance of the JR-DL for the reintegration process were rated high to moderate by more than 97.0 % of the OPs; 92.3 % of the patients received a recommendation to return to their previous workplace; 43.3 % returned with minor limitation; and the remaining 31.6 % with a recommendation for individual reintegration; 74.0 % of the workers returned to work within 3 days of discharge., Conclusions: Use of the JR-DL for the improvement of communication and exchange of relevant information is feasible and supportive for both rehabilitation and occupational physicians. Its positive impact on reintegration and return to work was apparent. Delays in receipt of the JR-DL should be eliminated by appropriate quality assurance measures.

Brain-derived neurotrophic factor (BDNF) has been known to play a role in fibromyalgia syndrome (FMS) patients. Depression and anxiety are quite common additional symptoms in FMS. However the role of BDNF in these symptoms still needs to be elucidated. Although BDNF has been shown to be relevant in major depression, however studies could not show such differences between FMS patients with and without major depression. As mood-related symptom occurs frequently and differs in its intensity in FMS patients, BDNF level should be measured in subgroup regarding depression and anxiety scale. Therefore the aim of this study was to evaluate the correlation of BDNF in serum of FMS with intensity of depression and anxiety. Additionally, interleukin (IL)-6 was measured. This study showed that serum level of BDNF was age-dependent in HCs. FMS patients had higher level of serum BDNF as compared to HC. Additionally, serum level of BDNF showed correlation with depression, but not with anxiety. Serum level of BDNF increased with depression score in FMS. However, serum level of IL-6 was not correlated with both depression and anxiety scores. Taken together, BDNF is involved in the pathophysiology of FMS. Additionally, it seems to be correlated with intensity of depressive symptoms in FMS., (Copyright © 2013 Elsevier Ltd. All rights reserved.)