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The SF-36 Health Survey and its 12-item abridged form is an instrument for the assessment of health related quality of life that can be used with healthy persons and patient populations. Its use has been recommended within a large German multicentre rehabilitation research programme. The paper examines missing data across all five study projects of the North German Network for Rehabilitation Research (NVRF) as well as psychometric properties of the instrument. In addition, data were compared to representative norm data using the SF-36 (SF-12) in the German National Health Survey. Results showed that there were few missing data in the SF-36. Examining the impact of age, gender and health status yielded effects of higher age and female gender on missing data. Psychometric analyses showed good to excellent results of the instrument in terms of scale fit and reliability. In terms of convergent validity, medium to high correlation of the SF-36 subscales with comparable instruments (e. g. SCL-90-R) could be found. Summarizing, the SF-36/SF-12 can be recommended for use in rehabilitation research. Analyses regarding sensitivity should be conducted in future studies.

Aim of the Study: The objective of this exploratory study was to examine the prevalence of overall pain generally and combinations of different pain locations, as well as their location, intensity, and duration in children and adolescents., Methods: After consent was granted by the local ethical committee and the Ministry for Education, Research, Science and Culture, modified versions of the structured pain questionnaire of Perquin et al. were submitted to 1077 parents, children,and adolescents in the Lübeck region of Germany. Of the 1077 questionnaires distributed, 1030 were returned (95.6%), and 991 of the 1030 questionnaires (96.2%) could be included in the analysis., Results: The prevalence of overall pain during the preceding 3 months was 80.1%, while the prevalence of pain in more than one region of the body during the preceding 3 months was 66.3%. Of the children and adolescents, 57% had headaches, 43.2% suffered from abdominal pain, 41.6% had limb pain, 32.9% had back pain, and 30% suffered from sore throats during the previous 3 months. A total of 30.7% of the children and adolescents with pain reported that the pain had already lasted for more than 6 months., Conclusions: Pain in general is very frequent in children and adolescents. Further studies are required to investigate chronic pain in children and adolescents.

Objective: Multidisciplinary team care is an opportunity to improve the long-term metabolic situation of patients with diabetes mellitus, hence can help reduce the individual and financial burden of diabetes-related complications. The aim of this study is to evaluate the extent to which patients undergoing rehabilitation carried by the German Federal Insurance Institute for Salaried Employees (BfA) were treated in accordance with recent evidence-based clinical practice guidelines on diabetes mellitus., Methods: We extracted specific treatment recommendations relevant to inpatient rehabilitation from national and international evidence-based guidelines and allocated them to general subjects of diabetes care (e. g. [disease specific] education, physical activity, psychosocial interventions). In the "Classification of Therapeutic Procedures (KTL)", an instrument used to classify therapeutic procedures in rehabilitation, we then identified those procedures that represented the recommendations of the guidelines. The coded procedures were allocated to the general aspects of diabetes care, too. In total, 9 "therapeutic modules" were designed, each containing guideline-recommendations and coded procedures. Using the KTL codes documented as a routine in discharge reports, we were able to describe, analyse and evaluate the procedures performed during rehabilitation. The data set we used contained KTL codes and medical information from 9,456 patients whose rehabilitation was carried by the BfA diagnosed with either diabetes mellitus type 1 or 2, who received an inpatient rehabilitation procedure during the years 2000 and 2001., Results: The number of patients who received at least one procedure out of the particular therapeutic module is as follows (numbers in brackets represent the total number of KTL codes in that therapeutic module): Therapeutic module "Education (3)" - 98.66 %, "Exercise Training (63)" - 92.42 %, "Nutrition Training (14)" - 96.44 %, "Stress (18)" - 35.33 %, "Motivation (15)" - 82.87 %, "Coping Skills (15)" - 27.42 %, "Social Work (26)" - 11.44 %, "Alcohol and Nicotine (24)" - 3.69 %, "Diabetic Complications (81)" - 75.42 %. On average patients received procedures out of 5.2 different therapeutic modules. The results were consistent over subgroups (type 1/type 2 diabetes, men/women) but varied considerably between clinics. The care provided in clinics with higher numbers of diabetic patients is more in line with guideline specifications., Discussion: A substantial number of patients received procedures out of the therapeutic modules "Education", "Exercise Training", "Nutrition Training" and "Motivation". In other therapeutic modules (e. g. "Alcohol and Nicotine") deficits were noted. These deficits as well as the substantial variation between clinics demonstrate the need to develop clinical practice guidelines for rehabilitation of patients with diabetes. In principle, the results of this study have to be interpreted carefully because we did not examine to which extent the documented processes are in accordance with the realities., Conclusions: Inpatient rehabilitation of diabetic patients carried by the BfA can be characterised as multidisciplinary and in accordance with the recommendations of recent evidence-based guidelines. Certain problematic aspects should be put into focus. A guideline taking into account all rehabilitative aspects, including the preparation for and the care after the rehabilitation process, can be instrumental in reducing deficits in rehabilitative care as well as differences between clinics. To gain wide acceptance, guideline development should be coordinated by a scientific institute and involve members of all groups concerned (e. g. the rehabilitative team, GPs, patients). Within certain limits the "KTL" instrument permits evaluation of process quality in rehabilitation of patients with diabetes mellitus.

The prevalence of chronic pain in the general population ranges from 10% to over 40%, depending on the investigation and definition. Chronic pain is tied to high direct and indirect costs for the health care system on the one hand and considerable personal impairment of the quality of life on the other. The present paper provides an overview of the frequency and distribution of chronic pain in the general population and among those receiving treatment. The limitations of epidemiological investigations lie in the difficulty of validly assessing subjective internal experiences of the patients. Moreover, it is not possible to make diagnoses in the proper sense. In contrast, the examination of patients seeking and receiving treatment offers a further diagnostic differentiation and better assessment of the qualitative aspects of the pain experience. However, the meaningfulness of these studies is also limited due to the qualitative problems. Despite the methodological limitations of the studies investigated, the wide distribution and meaning of chronic pain becomes clear particularly when evaluating studies on the general population and populations receiving treatment.

The guideline "Joint Swelling" is addressed to primary care physicians--general practitioners, internists or orthopedists without special experience in rheumatology. It provides a framework for interviewing patients, as well as for physical, laboratory and imaging examinations and for selection of treatment appropriate to the level of primary care. Situations which call for urgent evaluation and criteria for referral to rheumatologists are described. The appendix contains comments on signs and symptoms to differentiate arthralgia from joint swelling and on the diagnostic value of a history of joint swelling without confirmation by the physician. Further recommendations for the evaluation of patient history and physical and technical examinations are given in a tabular form. The significance of laboratory and imaging procedures is discussed.

The society of physicians of Germany and the society of panel physicians laid down in the "assessment criteria for guidelines in medical care" what kind of demands the medical selfadministration makes on guidelines. This measure also had the goal to support and strengthen the efforts of the AWMF for guidelines of high value. On the basis of these assessment criteria, a tool was compiled for the systematic registration and documentation of quality criteria for good guidelines for the first time in areas of German language. This check list is guided by the structure and content of the "Criteria for Appraisal for National Guidelines" by the Scottish Intercollegiate Guidelines Network.

Assessing working capacity in patients with chronic nonspecific pain disorders applying for disability pensions is a core tasks of practical social medicine. Traditionally the evaluation focused on the nosological classification and clinical description of the pain disorder with rather vague concepts of its consequences in terms of disabilities and handicaps. The author proposes to reverse the sequence. Following the International Classification of Impairments, Disabilities and Handicaps (WHO 1980) work incapacity can be seen as an "occupational handicap". Its qualities, severity and credibility depend on the existence of objectifyable disabilities (especially behaviour, locomotor, body disposition, dexterity and situational disabilities). These may be attributed to clinical impairments and an underlying disease process. Among impairments pain has to be assessed multidimensionally. As in clinical medicine a nosological diagnosis is a useful but neither necessary nor sufficient prerequisite for a sociomedical evaluation of pain patients.

Objective: To translate the Health Assessment Questionnaire Disability Index (HAQ) into a German version, to validate and to compare its properties with two different versions of the Hannover Functional Ability Questionnaire (HFAQ) in a German speaking population., Methods: The test-retest reliability was tested by Pearson correlation in 32 outpatients of the Department of Rheumatology of the Medizinische Hochschule Hannover. For retesting, the questionnaire was mailed to them 1 week later. To validate the questionnaire it was administered to 110 inpatients in three different hospitals. All patients fulfilled the American College of Rheumatology 1987 revised criteria of rheumatoid arthritis (RA) or the Rome criteria of definitive inactive RA. The internal consistency was measured by Cronbach's coefficient alpha (CCA). To assess criterion validity we compared the HAQ and the two versions of the HFAQ with Keitel's test (KT) and the modified Steinbrocker classification (mSC). Construct validity was assessed by comparing these instruments with different clinical and laboratory variables. A multivariate analysis was used to identify the most important factors that are influencing the HAQ- and HFAQ-scores., Results: Test-retest reliability of the HAQ was r = 0.94. CCA was 0.91 (HAQ), 0.90 (HFAQ-P) and 0.93 (HFAQ-PR). The KT Pearson correlation coefficients reached r = -0.73 (HAQ), r = +0.74 (HFAQ-P) and r = +0.71 (HFAQ-PR). The mSC correlated r = +0.75 (HAQ), r = -0.72 (HFAQ-P) and r = -0.70 (HFAQ-PR). The correlation coefficients of HAQ/HFAQ-P was r = -0.87 and of HAQ/HFAQ-PR r = -0.88. The correlations between other clinical and laboratory variables reached from r = +/-0.58 (pain/HAQ) to r = +/-0.11 (number of swollen joints/HFAQ-PR). In backward multiple regression analysis 59-64% of the variance of disability measured by the questionnaires was explained predominantly by pain (32-33%) and by range of motion (16-21%)., Conclusion: The German version of the HAQ presented here and the two versions of the HFAQ are reliable and valid instruments for measuring functional disability in a German-speaking population with RA. The construct measured by the HAQ and both versions of the HFAQ showed a high degree of correspondence.

All available data presented show that we are confronted with a back-pain (BP) epidemic; it affects numerous industrialized countries. More severe forms of BP make up one fifth of the prevalence. The greater part of BP seems to be mild, especially among persons aged 25 to 54. The social insurance statistics, too, show an alarming trend. Cases of work incapacity and medical rehabilitation have increased drastically: one sixth of all cases of work incapacity as well as one third of all medical rehabilitations are to be accounted to BP. It is not easy to interpret the data. Do they represent an increasing BP epidemic? A long-term secular trend towards higher BP prevalences at the population level is to be assumed but cannot be proven at the moment. Is there any evidence that BP-related risk factors have increased? To our knowledge there are no reliable data. It is also to be considered that the 'natural' course of BP may have changed. Is the epidemic a consequence of an increasing 'chronification' of BP due to physical, psychosocial or medical influences? Do 'back-schools' and other factors regarding the BP business have only health-promoting effects? Does the date represent a changing perception and appraisal of pain and/or a changing 'pain-reporting behaviour'? Is 'pain' today what would have been 'discomfort' in former times? Does one complain about BP today when one would have been silent in former times? There are no valid data for these hypotheses, either. Finally, has the transition probability from pain to disability and to social benefits changed?(ABSTRACT TRUNCATED AT 250 WORDS)

Back pain is occurring in a broad spectrum of severity; therefore, a grading procedure which is derived from a sound conceptual basis and can be easily applied is of crucial importance in clinical research and in epidemiologic studies. Following a grading procedure which has been developed in epidemiologic studies in the U.S., a hierarchical model for grading is proposed. This comprises pain intensity and functional limitation as basic criteria as well as aspects of time, pain-related cognitions/emotions and concomitant complaints. An application of a simple grading procedure is used to illustrate the predictive utility of the proposed model.

Rheumatic diseases, particularly those affecting the back, cervical spine, and the joints, are widespread in the general population. The general costs, especially those associated with social medical services, show constant increases. Time and effectiveness lost from work due to back problems in the FRG accounted for most of the days off the job because of disability, time spent in the hospital or at a health spa facility. Therefore, the appropriate evaluation of the degree of disability plays an increasingly important role in the area of social benefits. Yet unambiguous and objective physical measurements of the disease and the degree of associated disability are lacking in most cases of rheumatic diseases. More attempts to address the subjective aspects of the disease should be included in such evaluations. For recent years, models of measurement have been developed and tested, which are suited to the multidimensional nature of rheumatic illnesses. It is recommended that these be introduced in routine use for physical evaluations.

The aim of the study was the evaluation of a potential selection process for patients with rheumatoid arthritis (RA) referred to the Mobile Service for Rheumatics in Hannover (MSRH). The MSRH is the only referral center for patients with inflammatory rheumatic diseases in Hannover. A comparison of the health status was made between 58 individuals with RA identified in a population study, and 103 RA patients from the MSRH. The following disease parameters were less favorable in the clinical group: duration of morning stiffness, functional capacity, number of swollen joints, rheumatoid factor, ESR, disease activity, and classical RA according to the Rome-criteria. Only 22% of the individuals with RA identified in the population study have been referred to the MSRH. These patients more frequently had definite or classical RA (statistically not significant: p = 0.17, p = 0.11, respectively). It was shown that the clinical group comprised more severe RA cases. Thus, data from such patients may not be generalized for the entire group of RA cases in the population.

During the last few years epidemiologic research on rheumatic diseases in the Federal Republic of Germany has been sponsored, primarily, by the Ministry of Research and Technology. The projects, either completed, ongoing or planned, concentrate on health services research, population studies of the prevalence of specific diseases or complaints (rheumatoid arthritis, back pain, juvenile chronic arthritis, osteoarthritis) and clinical epidemiology, especially concerning early arthritis. As a result of the general shortage of public funds, less projects could be sponsored than expected. The aim of the Ministry to establish research organizations that will continue to exist even if public funding is curtailed seems to be jeopardized. Therefore, not only the federal government, but also the federal states and institutions like the Deutsche Forschungsgemeinschaft should be engaged in this field. More groups should have the opportunity to work in epidemiology of rheumatic diseases, and groups which are able to work in close connection with basic scientists and rheumatological clinicians should be institutionally affiliated on a permanent basis. This is critical for the further development of this discipline which is important for health services research, quality assurance, as well as for analytical research and prevention.

The fibromyalgia syndrome (FMS) is an extraarticular rheumatic disease. Typical features are the chronic, polytopic pain in the musculoskeletal system and the provocation of pain by pressure on defined tender points. Mainly medium age women are affected by the disease. In histomorphological studies of muscle tissue non-specific changes were demonstrated, which were thought to be due to ischemia. Furthermore, sleep disturbance and a reduced pain threshold, which may be related to psychological factors, are discussed in the etiology. In FMS a primary and a secondary form related to other diseases can be differentiated. The treatment consists mainly of behaviour therapy and physiotherapy.

Pain intensity and sensory dimensions of pain experience were studied in four samples totalling 346 patients with rheumatoid arthritis. 35%-61% of these patients suffer from severe pain. Arthritic pain is not automatically associated with emotional disorder. However, we met significant correlations of pain intensity with depression, trait anxiety, and state anxiety. Three hypotheses about the relation between pain and emotional state are discussed. Within one third of the patients we observed a paradoxical pain-mood pattern. Within the greater part of the patients severe pain is accompanied by considerable emotional suffering. The question of whether pain intensity is the cause of or the result from depression cannot be answered. However, predicting pain intensity from depression scores is much easier than predicting depression from pain intensity.

Activation of the complement system via immune complex formation plays an important role in the perpetuation of chronic inflammatory disorders. The serum levels of C3 or C4 do not necessarily reflect the actual complement catabolism. By measurement of the long-lived C3 split product "C3d" direct information about complement activation can be obtained. C3d was measured with a modified immunoelectrophoresis technique in EDTA-plasma of 106 patients with rheumatoid arthritis. 36% of them showed significantly elevated C3d levels (mean: 8.93 micrograms/ml). Significant linear correlations were found for C3d with ESR, Lansbury-Index and plasma viscosity.

The determination of the adequacy of an individual therapeutical regimen is part of the process evaluation of medical care. To evaluate the adequacy of individual antirheumatic therapy, we developed a five step procedure: 1. Assessment of the patient's health status; 2. assessment of his/her former and current therapy; 3. determination of the adequate antirheumatic therapy following an explicit norm; 4. formal comparison of current and adequate treatment; 5. clinical evaluation of possible differences between norm and reality. Due to methodological reasons we concentrated on the current treatment of rheumatoid arthritis (rA) patients with remission inducing drugs (RIDs; e.g. Chloroquine, Gold). The study analyzed the RID treatment of 75 rA-sufferers; 25 patients were referred to our outpatient department for the first time in late 1986; 25 patients were recruited from a social-medical study covering employed but actually disabled members of a major health insurance (AOK) in Hannover; 25 subjects were derived from an ongoing population study ("prevalence and care of rheumatoid arthritis in Hannover"). Only 9 out of 49 (18%) patients with an active disease, formally in need of treatment, were currently treated with RIDs. Thus 40 out of 49 (82%) seemed to be under an inadequate treatment. From the clinical point of view this formal judgement was assumed to be false positive in 5 and false negative in 15 cases. In relation to the clinical judgements we found for the formal procedure a sensitivity of 0.70 with a specificity of 0.80 and an overall agreement of 73% (kappa 0.44).

Between May 1986 and November 1987 we asked 4037 randomly sampled 25-74 year old german residents at Hannover (FRG) by a mailed questionnaire for back, neck and joint pain, for joint swelling and morning stiffness. Further we asked for the consultation of a physician during the past 12 months and for the use of drugs during the past 7 days because of rheumatoid complaints. 3426 members of the sample (85%) returned the questionnaire. 1828 (53%) reported at least one symptom "today" (= "the day you fill out this questionnaire"). The highest rate of persons suffering from complaints of the locomotor system was found among middle-aged women, with the maximum of 74% in the age group 50-54 years. For the illness behavior-physician consultation, use of drugs-the extent of complaints was of decisive importance. Sex was without, age of very low influence. The rate of those who reported the consultation of a physician and/or the use of drugs was increasing with the amount of positive answers to the questions on rheumatoid complaints. Nevertheless, of those who had answered in the affirmative all questions on complaints, 10% had denied the question on physician consultation. 41% had denied the question on the use of analgetic/antirheumatic drugs.

In the framework of an early-diagnosis out-patients clinic 100 patients (mean age 51 years), 82 of them female, were identified as highly suspicious of having chronic rheumatoid arthritis of recent onset (2-12 months). Five or more ARA criteria were present in 77 patients. IgM rheumatic factor was present in serum of 51 patients (latex-fixation test). A Waaler-Rose test of greater than or equal to 32 IU/ml was present in 21. After adjusting for alpha errors, there was a significantly higher prevalence of HLA-DR4 among those seropositive in the latex fixation test (64 vs 29%). A further 19 constitutional, anamnestic, clinical, biochemical and psychosocial criteria failed to reveal any different distribution between seropositive and seronegative cases. Using the specific definition of seropositivity in the Waaler-Rose test eliminated HLA-DR4 differences. The latter did not serve as a distinguishing criterion. There was only a marginal difference between DR4-positive and negative patients. These results fail to lend support to recent views of a special position of seronegative chronic rheumatoid arthritis.

Sixty-seven in-patients, admitted to neurological or surgical wards of an acute hospital, were repeatedly interviewed during an average stay of 15 days to test their need for information about their illness, their satisfaction with information received and their knowledge about their illness. Parallel to these interviews psychometric tests were performed on the second, seventh and penultimate day of the hospital stay, in the evening, to assess the extent of any disturbance in their subjective condition. Independent of the initial state, there were consistently less favourable results in those patient groups which (using several indicators) had a deficit in subjective information. These group-specific differences were in part statistically significant. An intervening influence of 12 personality dimensions was not definitely established. These findings support the hypothesis that deficient instruction and information of in-patients represents an important stress component which in the majority of these patients can give rise to an objectifiable psychosocial hospitalism.

A 36 week treatment with either salazosulfapyridine or aurothioglucose on 81 patients with definite and active rA, most of them from outpatient clinics, did not lead to significant differences in disability and pain intensity. Under both medications 40% were able to reach a statistically significant and clinically relevant improvement, while 25% remained in an unsatisfactory state.

During the winter term 1976/77 and in the summer term 1977 233 medical students of the fourth term were asked about their "attitudes and experiences" as "to which extent the patient wants to be and should be informed about his illness". About half of the investigated students--the number varies with the indicator--displayed attitudes and experiences corresponding to the patients' reality and needs. This was rated as an indicator of patient-centered orientation. The rest displayed patterns of attitudes and presuppositions similar to those we noted in physicians in hospital. The patients' great need of information is usually underrated, the individual aspects are not clearly recognized and there is only a slight inclination to tell the patient the whole truth, especially with regards to the prognosis. Age, sex, experiences in hospitals and professional objective of each of the investigated students do not have a relationship with these orientations. Having given a critical discussion of methods the authors demonstrate the didactic conclusions which the Marburg Institute of Medical Sociology would draw from its investigations.

Between 1984 and 1988 a community-based study of rheumatoid arthritis (RA) was undertaken in Hannover (Federal Republic of Germany) to determine patient characteristics and the patterns of antirheumatic treatment. Among 8044 randomly chosen German residents aged 25 to 74 years, we identified 45 persons suffering from RA; minimal prevalence 0.56% +/- 0.19%. Of these 45 RA-suffers only seven (16%) had consulted a rheumatologist (internist) "during the past 12 months". Only four (9%) persons were currently being treated with remission-inducing drugs (RIDs), e.g., chloroquine, gold. We could also ascertain low rates of physiotherapeutic treatment; "during the past 12 months" seven persons (16%) had received remedial gymnastics, one (2%) had received local application of cold. Our findings indicate that the treatment of RA in the population of Hannover is insufficient.