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In current and upcoming disease management programmes in Germany, the provision of medical services is strongly oriented on ICD diagnoses and on services traditionally provided by the statutory health insurance. Multidisciplinary services, such as medical rehabilitation, mostly covered by other payers (e.g. pension funds) are not taken into account. On the other hand, many chronically-ill patients have complex and multifocal health complaints that are best addressed by multidisciplinary interventions. Considering this inherent deficit, in 2002 the German Society of Rehabilitation Sciences has initiated the research project "Indication Guidelines" aimed at developing indication criteria for rehabilitation in the context of disease management programmes. The concept presented in this paper relies on three basic requirements: 1. Impaired participation (according to ICF) caused by multifocal deficits leads to the definition of goals for rehabilitation, taking into account clinical and legal aspects as well as the patients preferences. 2. Multifocal health problems are best addressed by a multidisciplinary rehabilitation programme as it is currently provided by the German pension funds. 3. Scientific evidence has to demonstrate that these programmes are very likely to be effective (positive rehabilitation prognosis, evidence-based rehabilitation). Further requirements include adequate instruction of patients, as well as intensive and prolonged after-care. Both could be very well integrated into comprehensive disease management programmes.

Item non-response is a potential threat to the validity of study results. Taking the somatisation subscale of the SCL-90-R as an example, we hypothesise a specific response pattern ("checklist-effect") that is characterised by symptom-free persons not checking the "not at all"-category. The present study analyses the extent and relevance of this postulated "checklist-effect". Our data is derived from a survey of n = 228 blue-collar workers who previously had filed applications for medical rehabilitation benefits (A1-study), and two additional surveys as well. We defined the "checklist-effect" by the following response pattern: (1) at least one missing value and (2) at least one valid item response and (3) no "not at all"-responses. Occurrence of the "checklist-effect" in the three datasets differed widely. 75 % of the responders in the A1-Study had complete data, 16.2 % a postulated "checklist-effect". Imputation of missing values under the assumption of a "checklist-effect" led to a reduction of missing data in the somatisation-subscale from 12.3 % to 0.4 %. Ignoring the "checklist-effect" would overestimate the symptom level. Possible explanations for the effect are discussed. However, the validity of this effect has yet to be proven via methodological studies.

Background: The ninth book of the German social code, SGB IX, has intensified questions on the effectiveness and usefulness of medical rehabilitation, a multimodal multidisciplinary team care model, especially but not exclusively for chronic back pain. In 2002 back pain was the reported leading cause for 29 % of all medical and other rehabilitative services provided by German statutory pension funds. A previous systematic review of all available German studies (January 1980 to June 2001) analysed the effectiveness of inpatient rehabilitation for chronic back pain. The present report provides an update and critical appraisal of the review., Method: Again we conducted a systematic search for relevant German studies from between July 2001 and December 2003 using electronic data bases, hand-searching of congress abstracts and postal questionnaires. The quality of relevant studies was assessed according to the recommendations of the Cochrane Back Review Group. For each study effect sizes for up to six central outcome parameters were calculated using pre-post comparisons from short and medium term follow-ups, they were correlated with prognostically relevant characteristics of the studies and samples. The combined weighted intra-group effect sizes were compared with results from international studies., Results: 16 studies, both controlled and uncontrolled, were included. Again we could not identify any study confirming the effectiveness of medical rehabilitation in chronic back pain compared to no treatment or usual care. The methodological quality of the new studies did not seem to exceed that of the earlier ones. Depending on the outcome variable, small effects (e. g. on functional ability) to relevant effects (e. g. vitality) can be observed at or immediately after the end of rehabilitation. Now the effects after three to 12 months seem to be smaller than previously observed., Discussion and Conclusions: The small size of medium term effects indicates a basic problem of inpatient rehabilitation for chronic back pain in Germany. This becomes even greater when the results of international controlled studies are used as reference. Possible reasons for the disappointing situation (weak methodology, inappropriate selection of patients, weak intervention) are to be discussed. At present, we have no convincing evidence for a general effectiveness of Germany's system of inpatient rehabilitation for chronic back pain.

The anthroposophic medicine plays a prominent role among the special forms of therapy. The concept of a cognition-based medicine (CBM)--in critical analogy to the evidence-based medicine (EBM)--has emerged from the circle of promoters of this type of therapy. The present paper attempts to identify common and different features of EBM and CBM. Criticisms of CBM to EBM are presented and addressed. The central aspect of the CBM concept is the single-case recognition, in analogy to the early gestalt-psychological considerations of Dunckers in the nineteen-thirties. The EBM can certainly accept the critical relevance and justification of this concept, particularly with regard to the constantly educational (self)evaluation of the clinical decision. Individual causal recognition, on the other hand, is unable to replace the summatory evaluation of controlled studies. In certain single cases, the CBM makes "evident" the effect of a given therapy, on the other hand it is unable to establish a generally valid efficacy, which is so critical for the orientation of patients, physicians, and the socially-based healthcare system.

Aim: Idiopathic (unspecific) low back pain is the most common rheumatological complaint. Results of international studies give evidence that in about 80 % of the cases a specific diagnosis is not possible, thus creating an unsatisfactory situation for the orthopaedist. We feel that it is necessary to keep the discussion on the rate of specific causes for low back pain open., Methods: In the context of a research project on the need for rehabilitation, 335 subjects suffering from severe low back pain were subjected to a physical (orthopaedic-neurological) examination. Also, a questionnaire was distributed assessing psychological status, work situation, comorbid conditions, risk factors, and demography., Results: In more than half of the subjects, clues for a specific cause for the back pain were found; in more than one third of the cases there were one or more neurological signs., Conclusion: The data presented demonstrate that specific causes for low back pain might be more common than generally assumed. This leads us to the conclusion that there is a need for more clinically-oriented, population-based (epidemiological) research on possible pathologic causes of low back pain and comorbid conditions.

When patient and physician (alone and together) make decisions on evidence-based therapeutic measures, the general efficacy and benefit of the measures have to be evaluated first. The second level of evaluation focuses on risks and benefits for the individual patient. The third level of evaluation focuses on whether the potential benefits can be achieved by the physician or clinic that have been chosen for treatment. Most often, indeed, the choice of a method (for example in-patient rehabilitation) influences also--directly or indirectly--the choice of a clinic and its equipment and personnel. The paper deals with the problems, data sources, and methods of comparison of clinic-specific efficacy. The limits of the quality-assurance program used thus far become also evident.

Study Design: Cross-sectional population-based study., Objectives: To assess whether the association between socioeconomic status and severe back pain can be explained by the preceding health care utilization for back pain., Summary of Background Data: The ways in which socioeconomic status affects the occurrence of back pain are unclear., Methods: Age- and gender-adjusted odds ratios with 95% confidence intervals for the association between indicators of socioeconomic status and severe current back pain (high intensity and/or high disability: no/yes) were investigated in an interview among 770 study participants out of 1113 study participants with a recent history of back pain in a survey among 2731 adults., Results: The point prevalence of severe current back pain (39.8%) was related to educational level and health insurance status. Prior health care utilization for back pain was about 2-fold more prevalent in adults with severe current back pain. Members of private health insurance (odds ratio 0.60, 95% confidence interval 0.37-0.99) were less likely to report prior consultation of a general practitioner for back pain. Members of sick funds for white-collar workers (odds ratio 2.81, 95% confidence interval 1.43-5.51) and private insurance (odds ratio 2.81, 95% confidence interval 1.02-6.24) and individuals with intermediate educational level (odds ratio 1.76, 95% confidence interval 1.05-2.95) utilized more physical therapy for the treatment of back pain. After additionally adjusting for health care utilization, the associations between educational level or health insurance status and severe current back pain remained unchanged., Conclusions: The data suggest that education, health insurance status, and health care utilization are independently associated with severe current back pain in a society with universal access to health care.

In 2002 a curriculum on evidence-based medicine (EbM) has been developed and published in Germany on behalf of the national statutory health care administrations. Planning and guiding medical education in EbM requires an empirically-based knowledge of the level of awareness and acceptance of EbM as well as specific educational needs and organisational preferences. In Germany, there is no such systematic knowledge, particularly in regard to general practitioners. A random sample of 900 office-based physicians in the German state of Schleswig-Holstein, stratified by medical specialties, was surveyed by means of a postal questionnaire. After two reminders the response rate was 65.6%. Respondents mainly welcomed EbM, in terms of their own daily work, for the benefit of the patient and the healthcare system as a whole. Integrating EbM into their daily practice and possible restrictions to therapeutic freedom were considered the most serious problems of EbM. 46.8% of the respondents were interested in EbM training. They preferred a rather low-cost 2-day weekend seminar. Office-based physicians were found to be sufficiently motivated to participate in EbM courses, which is in marked contrast to the actual participation rate being rather low in Schleswig-Holstein. The training should primarily focus on integrating EbM into daily routines. In public presentations efforts should be directed towards promoting the way in which EbM enhances professional autonomy and therapeutic freedom.

Study Design: Cross-sectional survey with personal interviews., Objective: To study national differences in subjective health, back pain, and self-perceived disability between the United Kingdom and Germany., Summary of Background Data: Back pain is a leading health problem in most Western populations, causing enormous costs to the national health systems. Different prevalence rates were reported from many countries, but rarely as a result of a direct comparison based on an identical study design., Methods: A total of 6,235 male and female participants 50 to 79 years of age (population-based stratified random samples) were recruited in 6 British and 8 German study centers. The interviewer administered standardized questionnaire included a section about presence and severity of back pain., Results: Past and current back pain was more frequent among German participants and different between East and West German centers. The differences in back pain prevalence rates could not be explained by less favorable risk profiles among German respondents., Conclusions: Intercultural differences in perceiving or reporting back pain can be hypothesized as the most likely explanation of the markedly different prevalence rates of the disorder in the United Kingdom and East and West Germany.

Background: Clinical observation suggests a frequent coincidence of back pain (BP) and fibromyalgia (FMA). Based on data from a population survey on back pain we studied the hypothesis of FMA being a frequent underlying condition of BP. We additionally studied the association of the severity of back pain and both chronic widespread musculoskeletal pain and active tender points., Probands and Methods: Data from a regional two-stage survey on urban German residents (aged 25-74 years) of Luebeck/Northern Germany (N=3969) were reanalyzed. The survey combined a postal questionnaire screening with a subsequent medical-psychological examination. Only subjects with back pain on the day of filling in the questionnaire were invited (n = 875). The response and participation rates were 82% and 73%, respectively. The severity of back pain was graded according to Kohlmann and Raspe (1994; based on pain severity and disability). In assessing widespread pain and tender points and classifying FMA-cases, we followed the criteria of the American College of Rheumatology (Wolfe et al. 1990). Standardized psychometric scales were used to measure general health status, bodily complaints, depressiveness, and catastrophizing cognitions., Results: In Luebeck, the overall point prevalence of back pain reached 39%. Among those invited and examined we found 27%, 25%, and 19% with back pain grade 1, 2 or 3, respectively. 29% reported no back pain on the day of examination. 12.6% of probands with actual back pain reported chronic widespread pain. The number of active tender points showed a significant and relevant association with back pain grade and was additionally correlated with all indicators of somatic and psychological distress., Conclusion: Our data do not support the hypothesis of FMA as a frequent underlying condition of BP. We found, however, a close correlation between BP grade (and amount of distress) and tender points count. More severe forms of BP imply an increasing allodynia/hyperalgesia, itself being associated with a higher amount of somatic and psychological distress (Chronic severe) back pain seems to be more than simply pain in the back.

Background: Vertebral fractures are associated with back pain and disability; however, relatively little is known about the impact of radiographic vertebral fractures on quality of life in population samples. The aim of this study was to determine the impact of a recent radiographic vertebral fracture on health-related quality of life (HRQoL)., Methods: Men and women aged 50 years and over were recruited from population registers in 12 European centers. Subjects completed an interviewer-administered questionnaire and had lateral spine radiographs performed. Subjects in these centers were followed prospectively and had repeat spinal radiographs performed a mean of 3.8 years later. Prevalent deformities were defined using established morphometric criteria, and incident vertebral fractures by both morphometric criteria and qualitative assessment. For each incident fracture case, three controls matched for age, gender, and center were selected: one with a prevalent deformity (at baseline) and two without prevalent deformities. All subjects were interviewed or completed a postal questionnaire instrument which included Short Form 12 (SF-12), the EQ-5D (former EuroQol), and the quality of life questionnaire of the International Osteoporosis Foundation (QUALEFFO). The median time from the second spinal radiograph until the quality of life survey was 1.9 years. Comparison between cases and their matched controls was undertaken using the signed rank test., Results: 73 subjects with incident vertebral fracture (cases), mean age 64.8 years (of whom 23 had a baseline deformity), and 196 controls, mean age 63.9 years (of whom 60 had a baseline deformity), were studied. There were strong correlations between the domain scores for each of the three instruments. There was no statistically significant difference in any of the domain scores between cases and those controls with a prevalent deformity. However, compared with the controls without a prevalent deformity the cases had significantly impaired quality of life as determined using the total QUALEFFO score (38.2 vs 33.7), the physical component score of the SF-12 (39.9 vs 43.7) and the health status score of the EQ-5D (62.3 vs 69.9). When the analysis was repeated after stratification of the cases by baseline deformity status (i.e., cases with and without a prevalent deformity at baseline), cases with a prevalent deformity had impaired quality of life compared with their matched controls, both with and without a prevalent deformity. In contrast there was no significant difference in quality of life among the cases without a prevalent deformity and either control group., Conclusions: In this population-based study a recent vertebral fracture was associated with impairment in quality of life, though this was mainly among those who had sustained a previous vertebral deformity.

In Germany evidence-based medicine has gained momentum not before the mid-1990ies. In particular, it started its career in the form of evidence-based health care. Within a few years (1999) the term even became part of Germany's social law. In contrast, clinicians and representatives of medical organisations are still sceptical and reluctant to adopt its concept, methods, and techniques. In part, their critical attitudes have been focusing on the perceived "deprofessionalisation" of the medical profession. Based on sociological and historical arguments and in view of the recently published "Charter on Medical Professionalism", the present paper reports and analyses this criticism. EbM, as an instrument of intraprofessional regulation, will most probably contribute to strengthening the autonomy of the medical profession; this, however, does not preclude the possibility that EbM may restrict the professional autonomy of individual physicians.

Chronic back pain is one of the most common and costly disorders. An overview shows that chronicity has various definitions, of which purely temporal ones predominate. Back pain is said to be "chronic" if it lasts for a variable number of weeks or months. Our attempt to refine such definitions is based on three previous works: Loeser's multidimensional pain model, the oncological TNM model and the International Classification of Functioning, Disability and Health of WHO (ICF). We suggest an unidirectional process of pain in the back to a complex pain syndrome including other types of pain, various bodily complaints and cognitive as well as emotional impairments, and propose an empirically testable research model.

The evaluation of disease management programmes is necessary and has been made obligatory in Germany by the Fifth Book of Social Code. So far there has been extensive ambiguity as regards the precise definition of suitable strategies for the evaluation. Considering the scientific evaluation of the diabetes contract in North-Rhine current deficits of the evaluation of already existing programmes for chronically ill patients are exemplarily described. On the basis of international experience reasonable demands are discussed that ought to be accomplished when evaluating the effectiveness and benefit of the programmes. Taking the British Medical Research Council as an example, a four-step model will be suggested as a loophole in the methodological dilemma of varying suitable study designs, which allows for the adequate evaluation of even complex interventions.

Background: Surveys with a main focus on back pain tend to isolate the complaint from possibly concomitant pains, other symptoms and disorders. Severe chronic back pain is assumed here to imply more than pain in the back., Participants and Methods: We report results from a two stage survey conducted in 1998 - 2000. The initial postal questionnaire addressed all 10,000 actively employed blue collar workers from a regional pension fund (Landesversicherungsanstalt Schleswig-Holstein) aged 40 - 54 and residing in or around Luebeck/Germany (68 % males). Subjects reporting severe and disabling back pain were invited to a socio-medical examination. The response and participation rates were 58 % and 65 % respectively. Non-response and non-participation seem to result in minor though opposite, effects., Results: The prevalence of current back pain (back pain of any severity within the past 7 days) is high (68 %; including 16 % with severe, disabling back pain) despite the preponderance of males and a probable healthy worker effect. 82 % of subjects participating in the second round reported recurrent or persisting back pain on the day of examination, in the majority with a chronic fluctuating and overall deteriorating course pattern. 18 % reported no current back pain and hence gave prospective (and additionally retrospective) evidence of an episodic-intermittent course of the disorder. The former group showed significantly more pains, bodily complaints, dysfunctional cognitions, emotional distress and concomitant disorders. 35 % of them indicated back pain as their dominant health problem; 49 % identified back pain and another disorder as dominant, and 16 % reported other prominent health problems. More than 70 % of "other" disorders originated from the musculoskeletal system often involving the extremities., Summary and Conclusion: Back pain is very common among blue collar workers. Severe disabling back pain is usually associated with numerous other pains, bodily complaints, disorders, and indicators of psychological distress ("amplified back pain"). However, even amplified back pain is not always the sole or dominant health problem. Assessing the degree of "amplification" seems helpful in splitting a previously homogeneous group of severely affected back pain sufferers-with possible prognostic and therapeutic consequences.

Objective: To examine the nosological concept of fibromyalgia in the general population., Methods: A postal survey of rheumatic pain and non-specific bodily complaints was sent to all 3174 German female residents of Bad Säckingen, Germany, aged 35 to 74 yr. A stratified random sample of 653 subjects was further examined in a clinical survey., Results: On the population level the point prevalence of chronic widespread pain was 13.5%. In the clinical survey, tender point count was associated not only with the extent of rheumatic pain, but also independently with the extent of bodily complaints. Subjects with no history of rheumatic pain but with non-specific bodily complaints had as many positive tender points as subjects without bodily complaints but with a history of rheumatic pain. Subjects could be identified who met the tender point criterion of the ACR without a history of widespread pain. Multivariate analyses demonstrated that some symptoms carry a risk for positive tender points (low physical mobility, pain, bodily complaints) and some for chronic widespread pain (poor health status, catastrophizing, emotional reactions, low energy level, sleep disturbances) that are independent of each other and of age., Conclusions: The results do not only question the relevance and specificity of a history of widespread pain in diagnosing fibromyalgia, but also the concept of fibromyalgia as a distinct rheumatological disorder. The results support the concept of fibromyalgia as part of a wider spectrum of dysfunctional syndromes.

The psychometric properties of a 3-item scale for the assessment of subjective vocational disability were tested in 4279 blue-collar workers. Internal consistency of the scale was estimated by Guttman scaling. To evaluate construct validity the scale was compared to other measures of vocational ability, functional capacity, comorbidity, psychic status, and indicators of occupational handicap. The results are highly satisfactory, and the scale can be recommended for further use in rehabilitation research. Ongoing research is discussed.

Background: Chronic back pain has a high personal impact, is frequent and of outstanding economical relevance. Analysis of the international literature indicates strong or moderate evidence for the effectiveness of multimodal multidisciplinary team care of chronic back pain. Our review aims at a complete review and critical appraisal of German studies of inpatient medical rehabilitation., Methods: We conducted a systematic search for relevant German studies (1/1980 - 6/2001) using electronic data bases, manual search of congress abstracts and postal questionnaires of 712 German rehabilitation clinics. Relevant studies were categorized according to the recommendation of the Cochrane Back Review Group. For all studies, aims, participants, type of intervention, evaluation time, main outcomes and results were extracted and tabulated. The effect size for 6 central outcome parameters (pain intensity, functional status, catastrophizing, depression, vitality, days on sickness leave) were calculated using pre-post comparisons and were integrated into short and long term weighted means of intra-group effect sizes., Results: 30 studies, both controlled and uncontrolled, report a multitude of positive changes with inpatient rehabilitation treatment. Improvements included both somatic and psychological parameters. However, methodological quality was often poor; only three studies fulfilled the criteria for high quality. Comparison of meta analyses of German and international studies indicates partly good agreement (e. g. changes in pain intensity), partly discrepancies (e. g. functional ability in daily activities). Taken together, inpatient rehabilitation treatment for chronic low back pain in Germany appears to be of low to moderate efficacy., Discussion and Conclusions: In the era of evidence based medicine, inpatient rehabilitation has to show its usefulness, necessity and efficiency as any other type of health care. For the German system of inpatient rehabilitation of chronic back pain available evidence is not conclusive, due to a lack of randomised controlled studies. The prevailing design of observational cohort studies has severe limitations in proving a causal relationship between outcomes and intervention. The international literature however provides more valid evidence in favour of the multimodal multidisciplinary intervention in chronic back pain. Under the assumption of a "class effect" of medical rehabilitation the German data seem to corroborate the conclusions drawn from international studies.

Objectives: Traditional pretests are used in the development of survey items to identify technical and comprehension problems. Cognitive processes involved in answering survey questions are not the object of this kind of test., Methods: Cognitive survey methods were used here to test a questionnaire screening for rehabilitation needs in people suffering from back pain. Essential techniques of cognitive testing (think-aloud, probing, confidence ratings) are outlined. We applied these techniques to 20 patients suffering from either acute or chronic back pain in order to test the survey., Results: The main goal, i.e., identifying problems in item formulation by means of cognitive testing, was achieved. Almost one third of the survey questions were rephrased according to the results of the study. Some of the improvements of the questionnaire are illustrated., Conclusions: The increased effort required to perform cognitive testing as compared to traditional pretesting pays off. The two methods have specific pros and cons and cannot replace one another.

Objectives: Vocational (dis-)ability is a central concept in social medicine. Beside from medical factors psychological and system factors play a crucial role in determining vocational disability. The development of instruments assessing the prognosis of gainful employment is an important task in rehabilitation research., Methods: A short scale measuring the subjective prognosis of gainful employment (SPE-scale) was administered to 481 blue collar workers suffering from severe back pain or else functional syndromes. Employment status two or three years following the assessment is known., Results: 11% of the subjects have applied for early retirement; 5% actually have retired. There are statistically significant relations of SPE-scores and subjects employment status. Effect sizes of the SPE-scores equal or even outrank those of other instruments assessing vocational (dis-)ability. The positive predictive power of the scale is low, though., Conclusions: The SPE scale can be recommended for further use in (rehabilitation) research. The employment of the instrument for medical appraisal has to be viewed with more caution. The percentage of subjects at risk for early retirement is largely overestimated in case of a positive test. Instruments like the SPE-scale can assist but never replace the medical appraisal.

There is important geographic variation in the occurrence of the major osteoporotic fractures across Europe. The aim of this study was to determine whether between-center variation in limb fracture rates across Europe could be explained by variation in the incidence of falls. Men and women, aged 50-79 years, were recruited from population-based registers in 30 European centers. Subjects were followed by postal questionnaire to ascertain the occurrence of incident fractures, and were also asked about the occurrence and number of recent falls. Self-reported fractures were confirmed, where possible, by review of the radiographs, medical record, or subject interview. The age- and gender-adjusted incidence of falls was calculated by center using Poisson regression. Poisson regression was also used to assess the extent to which between-center differences in the incidence of limb fractures could be explained by differences in the age- and gender-adjusted incidence of falls at those centers. In all, 6302 men (mean age 63.9 years) and 6761 women (mean age 63.1 years) completed at least one questionnaire concerning fractures and falls. During a median follow-up time of 3 years, 3647 falls were reported by men and 4783 by women. After adjusting for age and gender, there was evidence of significant between-center differences in the occurrence of falls. There was also between-center variation in the occurrence of upper limb, lower limb, and distal forearm fractures. Variation in the age- and gender-adjusted center-specific fall rates explained 24%, 14%, and 6% of the between-center variation in incidence of distal forearm and upper and lower limb fractures, respectively. Given the constraints inherent in such an analysis, in men and women aged 50-79 years, variation in fall rates could explain a significant proportion of the between-center variation in the incidence of limb fracture across Europe., (Copyright 2002 by Elsevier Science Inc.)

Type 2 diabetes is considered a multidimensional health impairment which includes several components like risk factors, cofactors and complications. The early and consequent therapy of all of these components reduces secondary complications. Instead of simply applying drug treatment, a more holistic concept including behavioural medicine therapy and empowerment of patients has been found much more effective. The facilities required for such a multifactorial therapy by different health care professions could easily be provided by the medical rehabilitation services available under the German pension insurance scheme. However, this emphasizes the demand for standardized protocols to achieve an objective allocation of rehabilitation services to individuals in need. In an epidemiological study on 12 429 working insurants (age 41 - 60 years) of the pension insurance fund in the region of Luebeck, persons suffering from type 2 diabetes were identified and evaluated regarding a need for medical rehabilitation. Therefore, an algorithm was developed quantifying the multidimensional disturbances which accumulate in type 2 diabetes mellitus. The following indicators are taken into consideration: risk factors like eating behaviour, lack of physical activity, smoking and stress; metabolic parameters such as HbA1c and plasma lipids; cofactors like hypertension and depression and, additionally, the acute complication of hypoglycaemia. Based on this rehabilitation score, 19 % of cases in a preliminary evaluation of 79 patients with type 2 diabetes showed a need for medical rehabilitation therapy.

Introduction: Prevalence of obesity has been on the increase in recent years. In contrast to obesity in adulthood, childhood obesity is still not uniformly defined. This results in problems to determine the need for medical rehabilitation., Methods: The Kiel Obesity Prevention Study (KOPS) is a cross-sectional study assessing the nutritional status of 5-7 year-old German children. Three different definitions of overweight and obesity (German reference data for triceps skinfold thickness [90(th) percentile] and BMI [90(th)/97(th) percentile] as well as an international standard for BMI [extrapolated to levels of adults]) were applied to 1,643 children of KOPS enrolled between 1996 and 2000 (19 % of all first-graders in Kiel in this period)., Results: The prevalence of overweight varies from 9 to 21 % depending on the applied definition. With the definitions of overweight and obesity based on newer BMI percentiles a part of overweight children are not classified as such. The present state of art is that there is only a need for obese children for medical rehabilitation: these are 3.3 and 3.5 % of 5-7 year-old children in Kiel, respectively., Conclusions: Experts should work out an agreement concerning a uniform definition of childhood obesity. Currently, medical rehabilitation services are offered only to extremely obese children. There is a need for more and earlier preventive measures.

Back pain constitutes a nearly universal experience, Point, one-year period and lifetime prevalence reach or exceed, in some European countries, 40%, 70% and 80%, respectively. No health care system is able to cope with the entire quantity and spectrum of cases. Clinically useful distinctions are urgently required. A basic classification distinguishes specific from non-specific cases. Non-specific back pain may then be graded on its actual severity in terms of pain intensity and disability. This already implies limited prognostic information. Staging assumes a more or less unidirectional course with definable phases and transition periods and definitely adds to prognosis (cf. the TNM-system in oncology). So far there seems to be no generally accepted staging system for chronic back pain, although some promising proposals can be presented. The disorder, once it has become chronic, has a rather unfavourable prognosis, although single episodes still have a high probability of completely resolving within a few weeks. An underestimated risk factor for a chronic-disabling course of current back pain is (besides its acute grade and stage) its previous history.

During its short life time evidence-based medicine (EbM) has been subject of partly fierce criticism, mainly from the side of the clinic. In Germany, Rogler and Schölmerich (September 2000) published a critical commentary on EbM in the Deutsche Medizinische Wochenschrift. Our text is intended as a rejoinder. It firstly aims at clarifying the concept of EbM, especially its contribution to the science of clinical medicine, and it secondly answers relevant details of Rogler and Schölmerich's criticism. Their text turns out to be a mixture of truly relevant remarks, exaggerations, misunderstandings and obvious errors.

Background: In Germany public opinion is increasingly in favour of being included in decisions on priority and rationalisation of health care, as practiced in other countries for years. One question is, which influence medical know-how and patients' experience have on the assessment of health services (importance or reimbursement of expenses). In addition to a representative survey it would be appropriate to include certain groups like physicians, medical students, nursing staff, patients and inhabitants of old people's homes in a relevant survey., Design: We conducted a survey of six groups, differing in medical know-how, personal affliction and age, by a highly standardized questionnaire. The group of physicians received the questionnaire by mail with one reminder. The questionnaire was handed out to the other groups (directly)., Setting: 150 practices of internal specialists and general practitioners in and around Lübeck, a preclinical and a clinical semester of the Medical University of Lübeck, an old people's home in Lübeck-Travemünde and a cardiological clinic for rehabilitation in Bad Segeberg., Subjects: 150 practising physicians (internal specialists, general practitioners), 100 medical students of a preclinical semester and another 100 of the fifth clinical semester, 100 patients in cardiological consulting hours in a cardiological clinic, 100 members of the nursing staff of the same clinic and 110 residents in an old people's home. The survey period was between December 1997 and February 1998., Instrument: The questionnaire was identical to a parallel public survey. On the one hand defined health services were assessed in respect of importance and reimbursement of expenses. On the other hand, more general questions were asked regarding possible ways of financing or economization in public health., Results: A response rate of 82% was achieved in the group of inhabitants of the old people's home. Doctors and students showed a response rate between 60% and 70%, while the response rate of patients and nursing staff was about 50%. A clear agreement between groups could be found in the evaluation of health services in the case of severe illnesses of children, which achieved the highest rating. The evaluation of health services of controversial effectivity like homoeopathic drugs or acupuncture varied most. There was a tendency in the patients' group to rate the importance of the listed health services higher than in the other groups, especially doctors and clinical students. All groups showed readiness to assign more financial consequences to patients with illnesses caused by the patient's behaviour, e.g. dangerous forms of sports or smoking., Conclusion: Laity as well as experts showed a distinct interest in the complex subject. Medical know-how goes along with a more critical evaluation of the importance of numerous indications. Patients distinguished less between different health services. The questionnaire showed that those directly concerned wish to be included in the discussion and feel that decisions concerning priority-setting in public health should not be left to politicians and health insurance companies alone.

Background: Statutory health insurance bodies in Germany are experiencing increasing deficits, which raises the demand for rationalising health benefits. This, however, requires the establishment of priorities unless absolutely necessary benefits have to be cut. In other words, we must examine the preferences, expectations and experiences of the insured population. Within the framework of this study, we tried to find out the preferences and assessment of health services by the German population in the Lübeck region., Design: Mail survey (questionnaire and two reminders) to register the preferences and attitudes to guaranteed medical services in the light of threatening deficits. The random sample was drawn by the residents' registration office in Lübeck, the criteria being an age of between 25 and 64 years, German nationality and principle domicile in Lübeck., Instrument: Postal questionnaire with 7 pages including 9 question complexes on the importance of preventive, curative and rehabilitative health services with 88 items and personal data., Results: We succeeded in contacting 992 persons and achieved a response rate of 64.1%. 67% of the participants (n = 634) conveyed about their opinion on economic decisions in health care. 12% refused any involvement. In respect of importance and the cost of medical interventions, preventive, curative and rehabilitative interventions for children have highest priority. In the curative and rehabilitative sphere the emphasis lies on the severity of the illness. Interventions with controversial effectiveness were rated less important by the respondents and hence these should not be financed by the health insurance companies in every case, in the opinion of the persons who had been questioned., Conclusions: The evaluation shows that most participants could cope quite well with this questionnaire and were ready to be involved in decisions concerning health care. Like the participants of Ann Bowling's survey about the investigation of preferences in the UK, our respondents give medical interventions for children (independent from the medical sector) a higher priority. Mit vorang. Satz weicht die engl. Zusammenfassung von der dt. Zusammenfassung ab Apart from this it is obvious that interventions with controversial effectivity should not be covered by the health insurance companies to the same extent as those with established effectivity, which is, in a way, in contrast to valid German legal regulations.

Since evidence-based decision making is increasingly gaining acceptance among German health care authorities the need for evidence-based support for time-critical decisions becomes obvious. The best method to identify and summarize the available evidence is the conduct of systematic reviews of the literature. However, generally systematic reviews are not applicable in matters of urgency, because of their time consuming preparation. Concepts for "rapid reviews" are urgently required which ensure that these reviews still produce reliable results. The article proposes strategies to accelerate the preparation of a systematic review and discusses their possible influences on the conclusions of the review. Research efforts are needed to clarify which of the accelerations actually yield valid results.

Assessing health care needs in populations has become a major activity of public health medicine worldwide. Its methodology has been developing mainly in the English-speaking world. Concept, methods, and techniques have not yet reached Germany though recently the national expert advisory council for the concerted action in health care (Sachverständigenrat für die Konzertierte Aktion im Gesundheitswesen) provided first "official" definitions of demand, supply, and need to identify over- and undersupply in health care. This article aims at defining, from a combined sociolegal and sociomedical perspective, the need for medical rehabilitation measures among insurees of German pension funds. According to section 15 SGB VI rehabilitation is conceived as a medically coordinated multimodal-multidisciplinary intervention with a cognitive-behavioural orientation. To objectify the need for rehabilitation a series of 9 questions was developed enquiring inter alia about the presence of a disease or disability, the extent or "amplification" of the disorder, its course pattern, the implied risk of permanent work disability and likely success of rehabilitation. Nonspecific back pain served as a paradigmatic condition. One of the main problems encountered is the presently small evidence base to arrive at the necessary prognostic and therapeutic judgements.

To a growing extent evidence-based clinical practice guidelines are considered helpful in supporting high quality medical care. Our study assessed the methodological quality of 20 clinical practice guidelines on the management of osteoporosis. Results indicated that only 2 out of 20 guidelines were developed with sufficient methodological rigour to be called evidence-based--none of them from Germany. Comparative reports including quality assessments may not only be helpful for clinicians to choose an appropriate guideline for their daily practice but also to stimulate guideline developers to use more rigorous methodology.

There is an ongoing controversy concerning the use of bone density measurements within therapeutic and preventive strategies of osteoporosis. Since there are no randomized controlled trials evaluating the effectiveness of bone density measurement with subsequent therapy we used a "critical pathway" model to determine possible benefit of tertiary, secondary and primary preventive strategies utilizing bone density measurement. In a first step data for fracture risk in each group are extracted from the literature. The second step outlines possible benefit from therapeutic studies. It may be estimated that in groups of patients with prevalent fractures use of bone density measurement and therapy according to bone density values may reduce fracture rates up to 30%. Bone density measurements performed with secondary preventive intent, however will probably lead to a reduction of fracture rates markedly below 10%. A set of risk factors that allows identification of a high risk group that may benefit from bone density measurement and subsequent therapy to a relevant extent remains to be developed. Primary preventive strategies do not require bone density measurements.

Study Design: Population-based cross-sectional postal survey and interview substudy., Objectives: To examine the association between socioeconomic status and severe back pain and to determine whether this association can be explained by occupational factors., Summary of Background Data: Like other disorders, back pain and its consequences are inversely related to indicators of high socioeconomic status., Methods: The associations between indicators of socioeconomic status and presence or severity of current back pain (no back pain or back pain of low intensity and low disability versus back pain with high intensity and/or high disability) were investigated in a survey among German adults 25 to 74 years of age (n = 2731) and an interview substudy of 770 participants with a recent history of back pain.-, Results: In the survey, educational level was inversely associated with back pain and severe current back pain. Similarly, in the interview substudy, educational level, vocational training, occupational class, household income, and health insurance status were inversely related to severe current back pain. Age-adjusted and gender-adjusted odds ratios were 0.36 (95% confidence interval [CI] 0.25-0.52) for immediate educational level and 0.37 (95% CI 0.18-0.73) for high educational level. Recalled work tasks at the onset of back pain were significant risk factors of severe current back pain (heavy physical work: odds ratio [OR] 1.77, 95% CI 1.06-2.93; work in bent position among males: OR 1.89, 95% CI 1.03-3.46). After adjusting for occupational class or work tasks, the association between educational level and severe current back pain remained unchanged.-, Conclusions: The findings support the hypothesis that severe back pain is less prevalent among adults of higher socioeconomic status. The underlying mechanism could not be explained by differences in self-reported occupational factors.

Objective: Vertebral deformity is associated with back pain and disability. The aim of this analysis was to determine whether location within the spine influences the strength of association between vertebral deformity, back pain and disability., Methods: Men and women aged 50 years and over were recruited from population registers in 30 European centres. Subjects were invited for an interviewer administered questionnaire, and for lateral spinal radiographs. The questionnaire included questions about back pain, general health and functional ability. The spinal radiographs were evaluated morphometrically and vertebral deformity defined according to the McCloskey-Kanis method., Results: 756 (11.7%) men and 885 (11. 8%) women had evidence of one or more vertebral deformities. Among women with a single deformity, after adjusting for age and centre, those with a lumbar deformity were more likely than those with a thoracic deformity to report back pain, both currently (OR=1.4; 95% CI 1.0, 2.0) and in the past year (OR=1.5; 95% CI 1.0, 2.3). No association was observed in men. Among women with two deformities, those with adjacent deformities were more likely than those with non-adjacent deformities to report poor general health (OR=2.2; 95%CI 0.9, 5.6), impaired functional ability (OR=1.9; 95%CI 0.8, 4. 7) and current back pain (OR=2.1; 95%CI 0.9, 4.9), though none of these associations were statistically significant. By contrast, among men, non-adjacent deformities were associated with impaired functional ability compared with those with adjacent deformities., Conclusion: Location within the spine influences the strength of association between self reported health factors and vertebral deformity.

Unlike services paid through the Federal German Health Insurance, applications for medical rehabilitation are granted based on defined criteria. In some cases, rehabilitation is granted without apparent reason. Seeking to minimize this problem, this study integrates information on the subjective health status into the decision-making process of medical examiners. The return rate of the postal questionnaire (87%) as well as the evaluation of the examiners documented the practicability of the approach. The interviewed applicants described themselves as more limited in their abilities on several health dimensions (ICIDH) compared to a population of prestationary interviewed rehabilitation patients, whereby the standard deviations in both populations were similar. Furthermore, the applicants rarely utilized complementary treatments and sociomedical/legal advice. A surprising result lies in the mostly non-existent association between the subjective health status and the medical decisions. This constitutes a significant difficulty in legitimizing the decision-making process of the medical examiners.

In Germany, the term "evidence-based medicine" still leads to confusion. To our continental understanding "evidence" refers to the self-evident, what is obvious and unequivocally clear without any methodological mediation. In English speaking countries, "evidence" is defined as available and disputable facts indicating whether or not a proposition is valid. In clinical medicine both types of evidence are indispensable. However at present "external (i.e. anglosaxon) evidence" from sound-evaluative clinical research is actually needed to define and justify clinical indication rules. The rationale of the concept is obviously consequentialistic, it primarily considers the clinical and community effectiveness of any medical intervention. The paper finally discusses some of the ethical problems involved in evidence-based medicine.

In population-based studies of osteoporosis, ascertainment of fractures is typically based on self-report, with subsequent verification by medical records. The aim of this analysis was to assess the validity of self-report of incident nonspine fractures using a postal questionnaire. The degree of overreporting of fracture (false positives) was assessed by comparing self-reports of new fracture from respondents in the multicenter European Prospective Osteoporosis Study with data from other sources including radiographs and medical records. In the analysis, 563 subjects reported nonspine fractures. Verification of the presence of fracture was possible in 510 subjects. Of these, fractures were not confirmed in 11% (false positives). The percentage of false positives was greater in men than in women (15% vs 9%, p = 0.04), and less for fractures of the distal forearm and hip than for fractures at other sites. In a separate study, the degree of underreporting (false negatives) was assessed by follow-up of 251 individuals with confirmed fracture ascertained from the records of fracture clinics in three European centers (Lubeck, Oviedo, Warsaw). Questionnaire responses were received from 174 (69%) subjects. Of these, 12 (7%) did not recall sustaining a fracture (false negatives). The percentage of false negatives was lower for hip and distal forearm fractures with only 3 of 90 (3%) such fractures not recalled. Using the combined data from both studies, of those who reported a 'date' of fracture on the questionnaire, 91% of subjects were correct to within 1 month of the actual date of the fracture. A postal questionnaire is a relatively simple and accurate method for obtaining information about the occurrence of hip and distal forearm fractures, including their timing. Accuracy of ascertainment of fractures at other sites is less good and where possible self-reported fractures at such sites should be verified from other sources.

In Germany, members of social insurance (e.g., pension) schemes have to apply for medical rehabilitation. Usually, the applications are the expression of a subjective demand. If the applications are granted this leads to the actual supply of medical rehabilitation services. Formerly, long waiting lists were common. These have been replaced by a new balance between demand (amount of applications), "offer" (capacity of rehabilitation clinics) and the amount of granted applications. In addition to these notions, the article develops the concept of need for rehabilitation services based on sociomedical indications. Consequently, the need for medical rehabilitation can--to a certain degree--be objectified. The concept of need should not be mixed up with that of demand: not every member of a social insurance scheme who objectively is in need of medical rehabilitation realizes the need, not everybody who realizes a need will apply for rehabilitation, and not all applications will be granted. The article gives an overview of different ways of needs assessment.

The survey "Determinants in Applying for Medical Rehabilitation" intended to examine the interest of using rehabilitation services among workers in need of rehabilitation and clarify the reasons for the decline in applications for rehabilitation since 1995. For this reason 4400 blue collar workers of the regional pension fund (2% of the LVA population aged 40-59 years) were asked with a postal questionnaire. The response rate was 64%. In order to ensure the validity of the intentions stated, the pension fund verified how many workers actually filed an application for medical rehabilitation during the following twelve months. A quarter of the workers answering considered themselves in need for rehabilitation. Of these, 41% intended to file an application, 34% intended not to do so and 25% were undecided. The main reasons for intending to apply were encouragement by the GP and family members as well as the expectation of improving the working capacity. After one year, only 11% of the workers who claimed themselves to be in need for rehabilitation had filed an application for rehabilitation. This low number of applications from workers in subjective need for rehabilitation indicates a deficit in medical rehabilitation provision.

Unlabelled: Based on data from a prospective observational cohort study the following article attempts to answer two key questions of rehabilitation research in Germany: (1) What are the utilization rates of rehabilitation measures in patients with long-term work-incapacity due to low-back pain? (2) In this group of patients: does participation in rehabilitation programs correlate with return to work? Patients with long-term work-incapacity due to low-back pain report a severely impaired health status (measured by FFbH, SF-36, numeric rating scale for pain intensity) which calls for comprehensive medical treatment and rehabilitation. 40.5% of study patients received first time medical rehabilitation between three months and one year after the beginning of long-term work-incapacity, 20.5% between one year and two years after the beginning of long-term work-incapacity. These figures were not influenced by age. Considering the severity of impairment we judge these rates as being quite low. There was no positive correlation found between utilization of medical rehabilitation measures or any other medical treatment and return to work. A positive correlation was observed for utilization of first time medical rehabilitation between three months to one year after the beginning of long-term work-incapacity and functional capacity. This effect was demonstrable for patients 50 years of age or younger., Conclusions: (1) In our cohort utilization of medical rehabilitation measures in patients with low-back pain and long-term work-incapacity is quite low. This suggests a considerable amount of underutilization. (2) In order to avoid underutilization the process of accessing medical rehabilitation within the German health care system should be critically reviewed. (3) In the given context of high unemployment rates and the German early pensioning system the use of "return to work" as the main criterion to judge effectiveness of rehabilitation measures remains debatable.