[Placebo forte: a contribution to the demystification of a therapeutic principle].
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Headache↗
Biomedical subjects
G S Barolin
Publications and source records attributed to G S Barolin.
[Chronified headache].
Paroxysmal headache of the migraine type as well as permanent undulating headache (which we call cephalea) can lead to chronification, both often mixes within the chronification. Existence of psychogenic factors (in the broader sense) favourises chronification of headache. A self supporting circulus vitiosus may arise, in combination with the cervical column, depressivity, whiplash-injury, chronical over-use of drugs (often not without an iatrogenic component), expertise situations. Therapeutically we emphasise a polypragmasy orientated on target-symptoms. Analgesics and tranquilizers want to be excluded as much as possible. Clearly indicated antidepressant are of great value, physiotherapy and psychotherapy as well. As ultima ratio we administer a neuroleptic sleeping cure.
Combined Modality Therapy↗
[Rehabilitation and psychotherapy].
Especially the chronically ill and disabled deserve to benefit from "socially integrated psychotherapy" in view of their specific situation of distress, which has often arisen without warning and unexpectedly. Dealing with bodily impairments, there are the so-called "organismic" methods using the hypnoid state as major component that have proven to be highly efficient. Dealt with are autogenic training, guided affective imagery, respiratory feedback and hypnosis. Hypnoid states can be regarded as a third basic state of consciousness in humans (besides waking and sleep). They play a major role in many forms of psychotherapy. The knowledge and selective use of underlying mechanisms enhance the potentialities of psychotherapy. The psychotherapeutic basic dialogue stays in constant accompanying function. We are opposed to a widespread misconception that psychotherapy is a method for the treatment of psychogenic disorders only. We obtained good results in the treatment of palsied patients of extrapyramidal and pyramidal type with hypnosis or autohypnosis as well as with our own model of group psychotherapy (autogenic training with concomitant analytic discussion, over a period of up to nine months). In this set-up we successfully mix patients with psychogenic and with somatogenic disorders. Although not a primarily psychotherapeutic method, respiratory feedback also makes use of the hypnoid state. Good results have been achieved with patients in rehabilitation and chronic pain sufferers. Occasional experience with guided affective imagery have been encouraging. We can conclude that psychotherapy with organically ill patients is indicated and promising. We need more appropriate training, supervision and concomitant scientific research.(ABSTRACT TRUNCATED AT 250 WORDS)
Activities of Daily Living↗
[Introduction of the Valduna-Reha Scale].
We present a rating scale for the progress in rehabilitation which has been developed and tested in the course of several years. It is of special suitability for the documentation of rehabilitation in cases of dysfunction of the central nervous system due to various syndromes arising from vascular, post-traumatic and post-operative causes. It comprises the essential somatic as well as psychological data and differentiates between specific (e.g. localised) symptoms and their effects on the individual's global functioning, especially within his (her) social sphere. Under this aspect our scale appears to be of optimal use, especially with regard to the requirement: "as simple as possible and as comprehensive as necessary". It modifies the criteria of the WHO regarding the threefold differentiation between impairment, disability and handicap, by the use of two levels of documentation, thereby gaining in validity.
Activities of Daily Living↗
[Psychotherapy in advanced age].
The ageing patient, especially in rehabilitation, faces an unknown and sometimes critical situation, in which he is as much in need of psychotherapy as he can benefit by it. Combinations of hypnoid techniques together with group interactions and analytically orientated verbal therapy have proved to be most suitable, bringing into action the somatotropic as well as the psychotropic effects of psychotherapy. Pleasure-orientation, variety and imagination as psychotherapeutic dimensions have to be integrated into rehabilitation, which otherwise would remain incomplete patchwork. We need a renaissance of general communicative culture in the first place, additionally specific verbal techniques for special (critical) situations, e.g. when talking to the incurably diseased, to his family, etc. Psychotherapeutic reasoning and acting must become part of the training and a permanent concomitant factor in all health professions. The same must hold good for public life, politics and society, if we strive for generally effective achievements for the ever-increasing number of elderly patients. It opens vast new fields of action for a new generation of psychotherapists who will be prepared to shed antiquated prejudiced stereotypes.
Adaptation, Psychological↗
[Concomitant depression and its treatment].
Accompanying depression is especially common in elderly, chronically ill patients and rehabilitation patients, where a physical illness and/or disablement is accompanied by depression. Treatment should always be focussed in a "polypragmatic" manner on both physical or psychic symptoms. In particular psychotherapy (see article by Barolin), pharmacotherapy (referred to in this article) and physiotherapy (described further in other literature) are of importance here. Advantage is to be taken of the polar dimensions of different types of antidepressant drugs, namely the increase in drive or sedating effects. However, the increased rate of side effects from some drugs among elderly patients is not to be ignored. Taking the above into consideration, the new antidepressant, Fluctine (Fluoxetine), has proved to be effective among our randomly selected patients. This is on account of its relatively fast onset of action, minimal side effects and its slight increase in drive. The group of non-responders (one third of the patients) showed no decrease in depressive symptoms when other antidepressants were substituted. As expected those patients suffering organic-brain illness responded worse and represent a large percentage of the non-responders. These data prove the results of previous findings that patients with organic-brain illness generally respond worse to antidepressant medication. Thus Fluctine can be recommended for elderly patients with accompanying depression.
Adaptation, Psychological↗
[15-year-factor analysis of multiple sclerosis].
The authors have conducted a longitudinal survey for a period of 14 years with 171 patients suffering from multiple sclerosis. In each case, therapeutic and diagnostic procedures were in accordance with the latest development. In almost half of the cases with a duration of illness up to 20 years the degree of impairment can be regarded as minimal, which can be used as an argument in favour of conscientious and continuous rehabilitative measures, including psychotherapy (this in opposition to a "rehabilitative pessimism"). Two thirds of the patients have been in employment with full working capacity during the first ten years of their illness. The consequences for social medicine and social policy are self-evident and imperative. In accordance with earlier studies, motor pareses are predominant among the first symptoms of multiple sclerosis, whereas disorders of cranial nerves, of urinary excretion and of cerebral function appear later in the course of the disease. Factor analysis did not yield any clues with respect to the predictability of the development of illness. Psychoreactive depression is relatively common in the earlier stages, later we can find somatogenic (psycho-organic) depressions, which respond relatively poor to treatment. Among the diagnostic tool, analysis of the critical flicker fusion frequency (CFFF) has proved to be very sensitive, by far not as cumbersome as visually evoked potentials and at least as reliable as the later. Therapeutic strategies should include: early treatment of any acute attack, consequent long-term care with modern nursing methods and rational concomitant medication, prophylaxis against infection. Multiple sclerosis represents itself as a problem of long-term rehabilitation, thus emphasizing the necessity of increased commitment to rehabilitation within a general framework of health care, which should include: a) better representation of rehabilitation as a discipline at the universities. b) systematic concomitant research in rehabilitation, c) legal and administrative adaptations, d) the development of a general "rehabilitation mentality" (as we have come to call it), which means involvement with the patient and his environment throughout his entire life-span.
Adult↗
[The confused and the demented patient as a problem in neuro-rehabilitation. Old-age rehabilitation].
Organic psychosyndromes may be classified 1) by the state of vigilance (agitated or reduced), 2) by the progress in time (episodic versus progressive), 3) by the presence or absence of brain-local or vegetative accompanying phenomena, 4) by etiology. The most frequent forms are: multi-infarct-dementia and primary degenerative dementia of Alzheimer's type. We must be aware that this didactic differential diagnosis in reality mostly shows overlapping criteria. Either more to the one side or more to the other. Etiological therapy (as well "vasoactive" as "nootropic") should in most cases be combined with therapy of underlying internistic (cardiac for example) and accompanying (infection for example) symptoms. Depression as a special frequent dimension needs special attention. Furthermore there are complex therapeutic possibilities in the social, recreative, psychologic, rehabilitative, psychotherapeutic etc. field. Relatives need to be treated concommitantly. Only thus scientific as well as human implications for rehabilitation can meet.
Aged↗
[The horse as an aid in therapy].
Physiotherapy on the back of the moved horse has two important dimensions: 1) The somatotropic effect regards mainly spasticity, ataxia, the vertebral column, the basis of the pelvis and the skin. 2) A general psychotherapeutic and psychohygienic effect is created by joy, change and new impetus in rehabilitation and by the emotional contact with the "comrade animal". Or unit was the first to introduce hippotherapy with adults in Austria. There is specially good experience with the spastic atactic component in multiple sclerosis. However other diagnosis as well showed good profit, such as stroke, etc. Some good effects in cephalaea patients indicate transition to riding as a medical pedagogic instrument with further transitions to psychosomatic patients. We want to proceed in this direction. Well organized hippotherapy is cheaper than the hydrotherapy (being current almost everywhere. Therefore opposition against the valuable hippotherapy by reasons of economics should be ruled out. Today's medicine goes farther and farther away from natural possibilities (slogan: "overtechnologized"). We see in hippotherapy an important counterweight in the sense of a valuable methodology towards holistic therapy especially in rehabilitation.
Animals↗
[Medical documentation exemplified by neurology. 20 years' experience--current challenges--future prospects].
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Diagnosis, Differential↗
[Headache: interdisciplinary cooperation].
Tendency towards subspecialization in medicine, especially in medical literature, endangers the patient who does not fit in one of the specialities. Hence he may be treated badly or not at all. Headache forms an interdisciplinary meeting point and shows this in high grade. Four following reviews of books on headache will demonstrate it. Each of it claims a good deal of competence and authority. In itself however the four books are widely contradictory. Our concept of multidimensional classification in headache builds up a planned polypragmasy using target symptoms. This is an attempt to evade such dilemma. Further seems to be needed: better knowledge of the marginal territories in our specialization, closer interdisciplinary cooperation and maybe a new organisation of medical system.
Austria↗
[Illness, anxiety and the physician. An example from neurology and neurorehabilitation].
There are rationally treatable fears arising from the acute situation (especially in rehabilitation patients) as well as the irrational anxieties of the mainly endogenous depressive. In the condition which we have come to call "concomitant depression", especially in neuro-rehabilitation, we can find both types of fear and anxiety, often in the same patient with mutual overlapping. In dealing with the fears of the incurably ill patient it is essential to know the phase-related progression in order to give empathy and help in entering the further phases at the appropriate times. It is important to know the "typical anxieties of the elderly" and to take them into account in concomitant psychotherapy, whereby group therapy has proved to be especially useful. On the other hand, the anxieties of the doctors themselves have to be dealt with, which opens a wide field for psychodynamic supervision and the Balint-groups. Apart from psychodynamic components there should however be a distinctly defined teaching program for the health profession, as well. On the therapeutic sector, we have to mention the organismic therapies, which have a good anxiolytic quality (therapy by hypnoid states and/or relaxation). Anxiety is by no means the only known contra-productive psychodynamic factor, but it is a point of onset for a desirable integrative approach in medicine, as a counterbalance against present tendencies towards over-specialisation, which at time can be counter-productive and detrimental to the patient. To achieve this, psychotherapy has to leave its ivory tower in order to radiate into all medical disciplines. It is not our task to eradicate anxiety in its pathological overflow by therapy; but to recognize and acknowledge it as an existing human dimension, thereby preventing it from turning into counter-productive moxiousness. Essential in this process are self-reflexion, empathy, training and systematic application of therapeutic techniques in efficient combination.
Anxiety Disorders↗
[Seizures in old age].
The important differential diagnosis between epileptogenic versus non-epileptogenic attacks becomes increasingly difficult with elderly patients: 1) Vasovagal syncopes may occur abruptly, not infrequently with injuries caused by the sudden fall ("Blitz-Synkope"). Other generalized non-epileptic seizures include drop-attacks, amnesic episodes, prolonged syncopes, and seizures caused by faulty metabolism. 2) Focal non-epileptic seizures in advanced age are mainly TIA and prolonged TIA (PRIND). Complicated migraine is more typical for the younger age group. In this connection it must be kept in mind that 10% of TIA are caused by brain tumor, 20% can be traced to cardiac origin. 3) In connection with the non-epileptic seizures mentioned above there may appear singular irregular cloni without any rhythmical sequence. We have come to call this type of attacks "incidental convulsions". Especially in these cases differential diagnosis is of great importance with respect to basically different therapeutic measures. 4) First manifestations of epilepsy in advanced age are--regarding etiology--in the first rank symptoms of cerebral vascular disease or of intracranial tumors. 5) In the diagnostic approach it is necessary to keep in mind all the above-mentioned possibilities and to exploit every possible access to anamnestic exploration, with the patient as well as with his family, friends and colleagues. Essential auxiliary diagnostic methods include EEG, computed tomography, Doppler-sonography, occasionally long-time EEG or ECG, in some cases NMR.
Aged↗
[The expertise situation as pathoplastic factor].
Underlying attitudes of apprehension or desire have an essential pathoplastic function, especially in the situation of medical assessment. The functionality of symptoms and complaints requires a diagnostic approach which is not oriented simply towards the "exclusion of organic causes". Interaction between somatogenic and psychogenic factors is by far more common than sheer functionality. Although widely neglected in our medical teaching and literature, these problems are not confined to the mere assessment of temporary or permanent invalidity, but are of great importance for the entire medical sphere, including manifestations and course of a disease, therapeutic success etc. In Austria, the population of foreign workers is in a special position due to socio-economic preconditions, partly due to short-sighted policy devoid of psycho-hygienic considerations. This situation requires thorough analysis free of emotions, which should lead to the development of sensible, although in some respects belated, measures. The latest economical recession has revealed several faulty courses of development in our system of social and health insurance, which needs revision urgently lest it should collapse. In this respect, the medical profession is called upon to contribute to a necessary curtailment of excessive misuse within a system that has become inflexible during the past decades, thereby endangering the valuable achievements of social medicine.
Adult↗
[Seizures and driver's licence].
Legislation leaves a wide margin of freedom of judgement to the medical expert in the forensic assessment of a person's suitability for holding a driver's license. We have to make use of this freedom very cautiously with regard to social aspects as well as to the presently accepted state of scientific knowledge. In cases of first manifestations of epilepsy we must postulate--as a rule of thumb--a seizure-free period of two years with regular medication and clinical and electro-encephalographic checkups. The (epileptic or non-epileptic) "accidental seizure" is characterized by the releasing influence of powerful external noxious factors. In these cases, the patients should be seizure-free for at least six months before driving can be resumed. In all cases, the evaluation depends on the continuous observance of the patients, taking into account any underlying primary illness (alcoholism, cerebral vascular disease, conditions following brain surgery or trauma). The organic brain syndrome is an essential additional factor, together with the feasibility of treatment and the patient's compliance. Evaluation of the clinical picture is of foremost importance, support by EEG-findings, serum levels and psychological tests. Knowledge of cumulative factors, elimination and side-effects of anticonvulsive drugs is essential. According to the present view, medication should be continued over a period of many years. Curative medicine and medical assessment are not mutually exclusive, but require a distinct differentiation in every single case.
Adult↗
[Valduna Rehab Scale in evaluating the correlation of clinical outcome and laboratory values in follow-up of encephalomalacia].
The clinical outcome of 65 patients with malazia alba of the brain was documented by the use of our "Valduna-Disability-Score" examining the patients at defined points of time. Simultaneously several rheological parameters of venous blood gained by punction of the cubital veine were examined before and after hemodilution therapy using dextran 40. The items or progress concerning clinical outcome and changes of the rheological parameters were correlated. There was not found any significance. We conclude, that the changes of rheological parameters in venous blood are not able to predict the clinical outcome after hemodilution therapy. The important role of disability scores--in our case the "Valduna-disability-score"--is to be stressed.
Activities of Daily Living↗
[Ten years neurologic follow up--part of the "Vorarlberg Rehabilitation Model"].
Within our framework of "comprehensive and permanent" rehabilitation, the follow-up neurological rehabilitation service is an important element. Based on the findings of an anterospective computerized documentation, a ten year survey is given concerning more than 600 patients and over 15,000 home visits. Aside general epidemiologic data, such as age, gender distribution, etc., our findings above all show that improvements in rehabilitation profiles can be achieved even after prolonged periods of time (i.e., 12 months and over) after onset. This, for one thing, may help in countering a widespread rehabilitation pessimism and, for another, serve in motivating the responsible cost-carrying agencies to pay increased attention to the field of neuro-rehabilitation. Literature concerning systematic assessment of long-term rehabilitation outcomes is sparse and fragmental. Available data to a large extent are in line with our findings. Further accompanying rehabilitation research into these respects is urgently needed. A number of important service delivery/organizational aspects have in addition been traced, which we are already trying to implement within our Vorarlberg rehabilitation model.
Activities of Daily Living↗
[Predictors of multiple sclerosis development trends with special reference to "questionable initial manifestations"].
Within 10 years we have had evidence in our department of 173 cases of proven multiple sclerosis (MS) and 63 cases which primarily were called by us: "bland entzündliches Geschehen" (BEG) instead of "possible first onset of multiple sclerosis". 44% of these cases remained as a singular manifestation, whereas 56% developed to established MS. This underlines our proposition of a new classification which does not call such questionable first symptoms as "possible first onset of MS" but as "bland entzündliches Geschehen". This is much less severe and prejudicatory for the bearers of such symptoms. Furthermore we could demonstrate clear correlations between clinical and laboratory findings and the probability of development of MS and the improbability of such a development, respectively. We could not find such predictors up till now in the literature. The several laboratory parameters, relevant for MS (not only with regard to BEG, but also to the whole population which clinically proven MS) could be tested regarding their sensitivity. As a remarkable result, to our knowledge not mentioned so far in the literature, we could demonstrate the flicker-fusion-analysis to be the leading laboratory test. In addition it is a very simple laboratory method, as far as time and money are concerned. It is at least as valid as visual evoked potentials which in the literature are considered to be the most sensible test. Taking into account the few cases examined with the magnet resonance tomography until today, this method, seems to be less sensitive than flicker-fusion-analysis. We do not have a 100% laboratory method at our disposal.(ABSTRACT TRUNCATED AT 250 WORDS)
Adolescent↗