#PAGE_PARAMS# #ADS_HEAD_SCRIPTS# #MICRODATA#

Multi-disciplinary interventions for chronic pain involving education: A systematic review


Autoři: Shirdhya Joypaul aff001;  Fiona Kelly aff001;  Sara S. McMillan aff001;  Michelle A. King aff001
Působiště autorů: School of Pharmacy and Pharmacology, Menzies Health Institute Queensland, Griffith University, Queensland, Australia aff001
Vyšlo v časopise: PLoS ONE 14(10)
Kategorie: Research Article
doi: https://doi.org/10.1371/journal.pone.0223306

Souhrn

Background

There have been growing recommendations to include education in multi-disciplinary interventions targeting chronic pain management. However, effects of this strategy on short- and long-term self-management of chronic pain, remain largely unexplored.

Objectives

1. To provide an updated overview of studies that report on the impact of patient education in multi-disciplinary interventions, on self-management of chronic pain; 2. To explore associations between education and chronic pain self-management techniques; and 3. To identify the format and duration of suitable chronic pain interventions targeted at patient self-management.

Methods

Design: Narrative systematic literature review of randomised or controlled study designs. Data Sources: PubMed, CINAHL, EMBASE, PsycINFO. Participants: Adult patients with chronic pain of any aetiology participating in multi-disciplinary programs that included education. Main outcome measures: Assessments of level of pain, function, quality of life, self-efficacy, self-management, and any other relevant assessments. Study Appraisal and Synthesis Methods: PRISMA guidelines, Cochrane Risk of Bias tool, and TIDieR model.

Results

Database searching identified 485 potential papers. After removal of duplicates, and irrelevant articles by title and abstract, 120 full-text articles were reviewed and 27 studies were included in this systematic review. Studies were predominantly from the United States (n = 8; 29.6%). Over one hundred outcome measures were identified across all studies, with significant variation also observed in terms of how chronic pain duration was defined, and how education was delivered to participants. Overall, positive benefits of education were reported.

Conclusions

Education, as part of multi-disciplinary programs, is likely to improve self-management and self-efficacy in people with chronic pain of any aetiology. Heterogeneity in terms of: chronic pain duration; educational resources; healthcare professionals; and outcome measures, were identified as limitations. Further research, in the form of Randomised Controlled Trials addressing these limitations, is recommended.

Klíčová slova:

Allied health care professionals – Database searching – Lower back pain – Myalgia – Pain management – Psychologists – Pain psychology – Neuropathic pain


Zdroje

1. Access Economics Pty Limited. The high price of pain: the economic impact of persistent pain in Australia. MBF Foundation; 2007.

2. Blyth F, March L, Brnabicc A, Jormd L, Williamson M, Cousins M. Chronic pain in Australia: a prevalence study. Pain. 2001;89: 127–34. doi: 10.1016/s0304-3959(00)00355-9 11166468

3. International Association for the Study of Pain. Chronic Pain has arrived in the ICD-11. 2019. Available from: https://www.iasp-pain.org/PublicationsNews/NewsDetail.aspx?ItemNumber=8340&navItemNumber=643

4. Tsang A, Von Korff M, Lee S, Alonso J, Karam E, Angermeyer M, et al. Common chronic pain conditions in developed and developing countries: gender and age differences and comorbidity with depression-anxiety disorders. J Pain. 2008;9(10): 883–91. doi: 10.1016/j.jpain.2008.05.005 18602869

5. Pain Australia. Painful Facts. 2017. Available from: http://www.painaustralia.org.au/about-pain/painful-facts

6. Flor H, Fydrich T, Turk DC. Efficacy of multidisciplinary pain treatment centres: a meta-analytic review. Pain. 1992;49: 221–30. doi: 10.1016/0304-3959(92)90145-2 1535122

7. Gatchel RJ, Okifuji A. Evidence-based scientific data documenting the treatment and cost-effectiveness of comprehensive pain programs for chronic non-malignant pain. J Pain. 2006;7: 779–93. doi: 10.1016/j.jpain.2006.08.005 17074616

8. Karjalainen K, Malmivaara A, van Tulder M, Roine R, Jauhiainen M, Hurri H, et al. Multidisciplinary rehabilitation for fibromyalgia and musculoskeletal pain in working age adults. Cochrane Database Syst Rev. 2000; 2: CD001984.

9. Australia Pain. National Pain Strategy Pain Management for all Australians: National Pain Summit initiative. 2011. Available from: http://www.painaustralia.org.au/improving-policy/national-pain-strategy

10. Breivik H, Collett B, Ventafridda V, Cohen R, Gallacher D. Survey of chronic pain in Europe: Prevalence, impact on daily life, and treatment. Eur J Pain. 2006;10: 287–333. doi: 10.1016/j.ejpain.2005.06.009 16095934

11. Campbell G, Darke S, Bruno R, Degenhardt L. The prevalence and correlates of chronic pain and suicidality in a nationally representative sample. Aust NZ J Psychiatry. 2015;49(9): 803–11.

12. Henschke N, Kamper SJ, Maher CG. The Epidemiology and Economic Consequences of Pain. Mayo Clin Proc. 2015;90(1): 139–47. doi: 10.1016/j.mayocp.2014.09.010 25572198

13. Phillips CJ. The cost and burden of chronic pain. Reviews in Pain. 2009;3(1): 2. doi: 10.1177/204946370900300102 26526940

14. Kerr S, Fairbrother G, Crawford M, Hogg M, Fairbrother D, Khor KE. Patient characteristics and quality of life among a sample of Australian chronic pain clinic attendees. Intern Med J. 2004;34: 403–9. doi: 10.1111/j.1444-0903.2004.00627.x 15271174

15. Moseley GL, Nicholas MK, Hodges PW. A randomized controlled trial of intensive neurophysiology education in chronic low back pain. Clin J Pain. 2004;20(5): 324–30. 15322439

16. Berwick DM, Budman S, Feldstein M. No clinical effect of back schools in an HMO: a randomized prospective trial. Spine. 1989;14: 338–44. doi: 10.1097/00007632-198903000-00016 2523581

17. Aberg J. Evaluation of an advanced back pain rehabilitation program. Spine. 1984;9: 317–8. doi: 10.1097/00007632-198404000-00018 6233720

18. Bergquist-Ullman M, Larsson U. Acute low back pain in industry: a controlled prospective study with special reference to therapy and confounding factors. Acta Orthop Scand. 1977;1–117.

19. Dehlin O, Berg S, Andersson GB, et al. Effect of physical training and ergonomic counselling on the psychological perception of work and on the subjective assessment of low-back insufficiency. Scand J Rehabil Med 1981;13: 1–9. 6455734

20. Goossens ME, Rutten-van Molken MP, Leidl RM, Bos SG, Vlaeyen JW, Teeken-Gruben NJ. Cognitive-educational treatment of fibromyalgia: a randomized clinical trial. II. Economic evaluation. J Rheumatol. 1996;23: 1246–54. 8823700

21. Klaber Moffett JA, Chase SM, Portek I, Ennis JR. A controlled, prospective study to evaluate the effectiveness of a back school in the relief of chronic low back pain. Spine. 1986;11: 120–2. doi: 10.1097/00007632-198603000-00003 2939571

22. Lankhorst GJ, Van de Stadt RJ, Vogelaar TW, Van der Korst JK, Prevo AJ. The effect of the Swedish Back School in chronic idiopathic low back pain: A prospective controlled study. Scand J Rehabil Med. 1983;15(3): 141–5. 6195731

23. Triano JJ, McGregor M, Hondras MA, Brennan PC. Manipulative therapy versus education programs in chronic low back pain. Spine. 1995;20(8): 948–55. doi: 10.1097/00007632-199504150-00013 7644961

24. Stankovic R, Johnell O. Conservative treatment of acute low-back pain. A prospective randomized trial: Mckenzie method of treatment versus patient education in “mini back school.” Spine. 1990;15: 120–3. 2139241

25. King MA, Sav A, McSwan J. A pilot study of a multidisciplinary clinical pain programme provided by the Gold Coast Medicare Local. IJPP. 2015;23(S1): 6.

26. Joypaul S, Kelly F, King MK. Turning Pain into Gain: Evaluation of a Multidisciplinary Chronic Pain Management Program in Primary Care. Pain Med. 2018(pny241): 1–9.

27. Scascighini L, Toma V, Dober-Speilmann S, Sprott H. Multidisciplinary treatment for chronic pain: a systematic review of interventions and outcomes. Rheumatology. 2008;47: 670–8. doi: 10.1093/rheumatology/ken021 18375406

28. Mitchell GK, Tieman JJ, Shelby-James TM. Multidisciplinary care planning and teamwork in primary care. Med J Aust. 2008;188(8 Suppl): S61–4. 18429739

29. Barlow J, Wright C, Sheasby J, Turner A, Hainsworth J. Self-management approaches for people with chronic conditions: a review. Patient Educ Couns. 2002;48: 177–87. doi: 10.1016/s0738-3991(02)00032-0 12401421

30. Berube M, Choinière M, Laflamme YG, Gelinas C. Acute to chronic pain transition in extremity trauma: A narrative review for future preventive interventions (part 2). Int J Orthop Trauma Nurs. 2017;24: 59–67. doi: 10.1016/j.ijotn.2016.04.001 27527536

31. Geneen LJ, Martin DJ, Adams N, Clarke C, Dunbar M, Jones D, et al. Effects of education to facilitate knowledge about chronic pain for adults: a systematic review with meta-analysis. Syst Rev. 2015;4: 132. doi: 10.1186/s13643-015-0120-5 26428467

32. Liegl G, Boeckle M, Leitner A, Pieh C. A meta-analytic review of brief guided self-help education for chronic pain. Eur J Pain. 2016;20(10): 1551–62. doi: 10.1002/ejp.881 27161217

33. Abbasi M, Dehghani M, Keefe F, Jafari H, Behtash H, Shams J. Spouse-assisted training in pain coping skills and the outcome of multidisciplinary pain management for chronic low back pain treatment: A 1-year randomized controlled trial. Eur J Pain. 2012;16(7): 1033–43. doi: 10.1002/j.1532-2149.2011.00097.x 22337646

34. Anderson B, Strand LI, Råheim M. The effect of long-term body awareness training succeeding a multimodal cognitive behavior program for patients with widespread pain. J Musculoskelet Pain. 2007;15(3): 19–29.

35. Bair MJ, Ang D, Wu J, Outcalt SD, Sargent C, Gerwig A, et al. Evaluation of stepped care for chronic pain (ESCAPE) in veterans of Iraq and Afghanistan: A randomized trial. JAMA Intern Med. 2014;29: S89.

36. Basler HD, Jäkle C, Kröner-Herwig B. Cognitive-behavioral therapy for chronic headache at German pain centers. Int J Rehabil Health. 1996;2(4): 235–52.

37. Becker N, Sjøgren P, Bech P, Olsen AK, Eriksen J. Treatment outcome of chronic non-malignant pain patients managed in a Danish multidisciplinary pain centre compared to general practice: A randomised controlled trial. Pain. 2000;84(2–3): 203–11. doi: 10.1016/s0304-3959(99)00209-2 10666525

38. Beltran-Alacreu H, López-de-Uralde-Villanueva I, Fernández-Carnero J, La Touche R. Manual Therapy, Therapeutic Patient Education, and Therapeutic Exercise, an Effective Multimodal Treatment of Nonspecific Chronic Neck Pain: A Randomized Controlled Trial. Am J Phys Med Rehabil. 2015;94(10): 887–97.

39. Burke AL, Denson LA, Mathias JL. Does a Brief Educational Session Produce Positive Change for Individuals Waiting for Tertiary Chronic Pain Services? Pain Med. 2016;17(12): 2203–17. doi: 10.1093/pm/pnw125 28025355

40. Cherkin DC, Eisenberg D, Sherman KJ, Barlow W, Kaptchuk TJ, Street J, et al. Randomized trial comparing traditional Chinese medical acupuncture, therapeutic massage, and self-care education for chronic low back pain. Arch Intern Med. 2001;161(8): 1081–8. doi: 10.1001/archinte.161.8.1081 11322842

41. Corson K, Doak MN, Denneson L, Crutchfield M, Soleck G, Dickinson KC, et al. Primary care clinician adherence to guidelines for the management of chronic musculoskeletal pain: Results from the study of the effectiveness of a collaborative approach to pain. Pain Med. 2011;12(10): 1490–501. doi: 10.1111/j.1526-4637.2011.01231.x 21943325

42. Cramer H, Lauche R, Hohmann C, Lüdtke R, Haller H, Michalsen A, et al. Randomized-controlled trial comparing yoga and home-based exercise for chronic neck pain. Clin J Pain. 2013;29(3): 216–23. doi: 10.1097/AJP.0b013e318251026c 23249655

43. Ersek M, Turner JA, Cain KC, Kemp CA. Results of a randomized controlled trial to examine the efficacy of a chronic pain self-management group for older adults. Pain. 2008;138(1): 29–40. doi: 10.1016/j.pain.2007.11.003 18086516

44. Gallagher L, McAuley J, Moseley GL. A randomized-controlled trial of using a book of metaphors to reconceptualize pain and decrease catastrophizing in people with chronic pain. Clin J Pain. 2013;29(1): 20–5. doi: 10.1097/AJP.0b013e3182465cf7 22688603

45. Heutink M, Post MWM, Bongers-Janssen HMH, Dijkstra CA, Snoek GJ, Spijkerman DCM, et al. The CONECSI trial: Results of a randomized controlled trial of a multidisciplinary cognitive behavioral program for coping with chronic neuropathic pain after spinal cord injury. Pain. 2012;153(1): 120–8. doi: 10.1016/j.pain.2011.09.029 22100355

46. Jay K, Brandt M, Jakobsen MD, Sundstrup E, Berthelsen KG, Schraefel M, et al. Ten weeks of physical-cognitive-mindfulness training reduces fear-avoidance beliefs about work-related activity: Randomized controlled trial. Medicine. 2016;95(34).

47. Keller S, Ehrhardt-Schmelzer S, Herda C, Schmid S, Basler H. Multidisciplinary rehabilitation for chronic back pain in an outpatient setting: A controlled randomized trial. Eur J Pain. 1997;1(4): 279–92. 15102393

48. Kerns RD, Burns JW, Shulman M, Jensen MP, Nielson WR, Czlapinski R, et al. Can we improve cognitive-behavioral therapy for chronic back pain treatment engagement and adherence? A controlled trial of tailored versus standard therapy. Health Psychol. 2014;33(9): 938–47. doi: 10.1037/a0034406 24295024

49. Kristjánsdóttir OB, Fors EA, Eide E, Finset A, Stensrud TL, van Dulmen S, et al. A smartphone-based intervention with diaries and therapist-feedback to reduce catastrophizing and increase functioning in women with chronic widespread pain: randomized controlled trial. J Med Internet Res. 2013;15(3).

50. Martín J, Torre F, Padierna A, Aguirre U, González N, García S, et al. Six-and 12-month follow-up of an interdisciplinary fibromyalgia treatment programme: results of a randomised trial. Clin Exp Rheumatol. 2012;30(6 Suppl 74): 103–11. 23261008

51. Nicholas MK, Asghari A, Blyth FM, Wood BM, Murray R, McCabe R, et al. Self-management intervention for chronic pain in older adults: A randomised controlled trial. Pain. 2013;154(6): 824–35. doi: 10.1016/j.pain.2013.02.009 23522927

52. Pires D, Cruz EB, Caeiro C. Aquatic exercise and pain neurophysiology education versus aquatic exercise alone for patients with chronic low back pain: A randomized controlled trial. Clin Rehabil. 2015;29(6): 538–47. doi: 10.1177/0269215514549033 25200879

53. Ribeiro LH, Jennings MF, Jones A, Furtado R, Natour J. Effectiveness of a back school program in low back pain. Clin Exp Rheumatol. 2008;26(1): 81–8. 18328151

54. Ryan CG, Gray HG, Newton M, Granat MH. Pain biology education and exercise classes compared to pain biology education alone for individuals with chronic low back pain: A pilot randomised controlled trial. Man Ther. 2010;15(4): 382–7. doi: 10.1016/j.math.2010.03.003 20359937

55. Smith N, Jordan M, White R, Bowman J, Hayes C. Assessment of Adults Experiencing Chronic Non-Cancer Pain: A Randomized Trial of Group Versus Individual Format at an Australian Tertiary Pain Service. Pain Med. 2016;17(2): 278–94. doi: 10.1093/pm/pnv048 26814305

56. Sullivan MD, Turner JA, DiLodovico C, D'Appollonio A, Stephens K, Chan YF. Prescription Opioid Taper Support for Outpatients With Chronic Pain: A Randomized Controlled Trial. J Pain. 2017;18(3): 308–18. doi: 10.1016/j.jpain.2016.11.003 27908840

57. Turner-Stokes L, Erkeller-Yuksel F, Miles A, Pincus T, Shipley M, Pearce S. Outpatient cognitive behavioral pain management programs: a randomized comparison of a group-based multidisciplinary versus an individual therapy model. Arch Phys Med Rehabil. 2003;84(6): 781–8. doi: 10.1016/s0003-9993(03)00015-7 12808527

58. Uebelacker LA, Weisberg RB, Herman DS, Bailey GL, Pinkston-Camp MM, Garnaat SL, et al. Pilot Randomized Trial of Collaborative Behavioral Treatment for Chronic Pain and Depression in Persons Living with HIV/AIDS. AIDS Behav. 2016;20(8): 1675–81. doi: 10.1007/s10461-016-1397-7 27115400

59. Chao MT, Hurstak E, Leonoudakis-Watts K, Sidders F, Pace J, Hammer H, et al. Patient-Reported Outcomes of an Integrative Pain Management Program Implemented in a Primary Care Safety Net Clinic: a Quasi-experiemental Study. J Gen Intern Med. 2019;34(7): 1105–7. doi: 10.1007/s11606-019-04868-0 30783878

60. Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Br Med J. 2009;339: 332–6.

61. The Cochrane Collaboration. Cochrane Community Searching: Recording and Reporting. 2019. Available from: https://community.cochrane.org/organizational-info/resources/resources-groups/information-specialists-portal/searching-recording-reporting

62. Equator network. Enhancing the QUAlity and Transparency Of health Research. Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. Available from: www.equator-network.org/reporting-guidelines/prisma/

63. Training Cochrane. Assessing risk of bias in included studies. Available from: https://pdfs.semanticscholar.org/b2e5/4b74b82ab219236c8a595be2e0f7eb9836e1.pdf

64. Higgins JPT, Altman DG, Gotzsche PC, Juni P, Moher D, Oxman AD, et al. The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials. BMJ. 2011;343: 1–9.

65. Higgins J, Green SM. Cochrane handbook for Systematic Reviews of Interventions: The Cochrane Collaboration; 2011.

66. The TIDieR (Template for Intervention Description and Replication) Checklist. Available from: www.equator-network.org

67. Hoffmann TC, Glasziou PP, Boutron I. Better reporting of interventions: template for intervention description and replication (TIDieR) checklist and guide. Br Med J. 2014;348: g1687.

68. Popay J, Baldwin S, Arai L, Britten N, Petticrew M, Rodgers M, et al. Guidance on the Conduct of Narrative Synthesis in Systematic Reviews. Lancaster University. 2006. Available from: http://www.ccsr.ac.uk/methods/publications/documents/Popay.pdf

69. Hunt T, Wilson CJ, Caputi P, Woodward A, Wilson I. Signs of current suicidality in men: A systematic review. PLoS ONE. 2017;12(3): e0174675. doi: 10.1371/journal.pone.0174675 28355268

70. Roland Morris Disability Questionnaire. Available from: www.rmdq.org

71. Physiopedia. Visual Analogue Scale. Available from: https://www.physio-pedia.com/Visual_Analogue_Scale

72. Stewart M. The Medical Outcomes Study 36-item short-form health survey (SF-36). Aust J Physiother. 2007;53(3): 208. 17899676

73. Nicholas MK. The pain self‐efficacy questionnaire: Taking pain into account. Eur J Pain. 2007;11(2): 153–63. doi: 10.1016/j.ejpain.2005.12.008 16446108

74. Nicholas MK. Self-Efficacy and Chronic Pain. Annual Conference of the British Psychological Society. 1989.

75. Bennett MI, Bagnall A, Closs SJ. How effective are patient-based educational interventions in the management of cancer pain: Systematic review and meta-analysis. Pain. 2009;143: 192–9. doi: 10.1016/j.pain.2009.01.016 19285376

76. Engers AJ, Jellema P, Wensing M, van der Windt DAWM, Grol R, van Tulder MWC, et al. Individual patient education for low back pain. Cochrane Database Syst Rev. 2008;1: CD004057.

77. Kenny DT. Constructions of chronic pain in doctor-patient relationships: bridging the communication chasm. Patient Educ Couns. 2004;52: 297–305. doi: 10.1016/S0738-3991(03)00105-8 14998600

78. Darlow B, Fullen BM, Dean S, Hurley DA, Baxter GD, Dowell A. The association between health care professional attitudes and beliefs and the attitudes and beliefs, clinical management, and outcomes of patients with low back pain: A systematic review. Eur J Pain. 2012;16: 3–17. doi: 10.1016/j.ejpain.2011.06.006 21719329

79. The Royal Australian College of General Practitioners. The RACGP Curriculum for Australian General Practice. 2016. Available from: http://curriculum.racgp.org.au/statements/multidisciplinary-care

80. Rodondi P-Y, Dubois J, Bill A-S, Koutaissoff D, Ros J, Aveni E, et al. Primary care physicians' attitude and reported prescribing behavior for chronic low back pain: An exploratory cross-sectional study. PLoS ONE. 2018.

81. Occupational Therapy Australia. About Occupational Therapy. 2019. Available from: https://www.otaus.com.au/about/about-ot

82. Harvard Medical School. Can diet heal chronic pain? United States of America: Harvard Health Publishing; 2018. Available from: https://www.health.harvard.edu/pain/can-diet-heal-chronic-pain

83. Allied Health Professions Australia. Australian Association of Social Workers. 2017. Available from: https://ahpa.com.au/our-members/australian-association-of-social-workers/

84. Asghari A, Nicholas MK. Pain self-efficacy beliefs and pain behaviour. A prospective study. Pain. 2001;94(2001): 85–100.

85. Nicholas MK, Asghari A, Blyth FM. What do the numbers mean? Normative data in chronic pain measures. Pain. 2007;134(2008): 158–73.

86. Tay TG, Willcocks AL, Chen JF, Jastrzab G, Khor KE. A Descriptive Longitudinal Study of Chronic Pain Outcomes and Gender Differences in a Multidisciplinary Pain Management Centre. Pain Studies and Treatment. 2014;2: 56–9.

87. Bandura A. Self-Efficacy: Toward a Unifying Theory of Behavioural Change. Psychol Rev. 1977;84(2): 191–215. doi: 10.1037//0033-295x.84.2.191 847061

88. Miles CL, Pincus T, Carnes D, Taylor SJC, Underwood M. Measuring pain self-efficacy. Clin J Pain. 2011;27: 461–70. doi: 10.1097/AJP.0b013e318208c8a2 21317778

89. Sarda JJ, Nicholas MK, Pimenta CAM, Asghari A. Pain-related self-efficacy beliefs in a Brazilian chronic pain patient sample: a pyschometric analysis. Stress Health. 2007;23: 185–90.

90. Richardson JR, Peacock SJ, Hawthorne G, Iezzi A, Elsworth G, Day NA. Construction of the descriptive system for the assessment of quality of life AQoL-6D utility instrument. Health Quality Life Outcomes. 2012;10(1): 1.

91. BMJ Best Practice. What is GRADE? 2019. Available from: https://bestpractice.bmj.com/info/us/toolkit/learn-ebm/what-is-grade/

92. Johnson MI, Elzahaf RA, Tashani OA. The prevalence of chronic pain in developing countries. Pain Manage. 2013;3(2): 83–6.

93. Rathbone J, Carter M, Hoffmann T, Glasziou P. A comparison performance of seven key bibliographic databases in identifying all relevant systematic reviews of interventions for hypertension. Syst Rev. 2016;5(27).

94. Salkind NJ. Follow-Up. Encyclopedia of Research Design. 2010. doi: 10.4135/9781412961288

95. Cotterill S, Knowles S, Martindale A-M, Elvey R, Howard S, Coupe N, et al. Getting messier with TIDieR: embracing context and complexity in intervention reporting. BMC Med Res Methodol. 2018;18(12): 1–10.


Článek vyšel v časopise

PLOS One


2019 Číslo 10
Nejčtenější tento týden
Nejčtenější v tomto čísle
Kurzy

Zvyšte si kvalifikaci online z pohodlí domova

KOST
Koncepce osteologické péče pro gynekology a praktické lékaře
nový kurz
Autoři: MUDr. František Šenk

Sekvenční léčba schizofrenie
Autoři: MUDr. Jana Hořínková

Hypertenze a hypercholesterolémie – synergický efekt léčby
Autoři: prof. MUDr. Hana Rosolová, DrSc.

Svět praktické medicíny 5/2023 (znalostní test z časopisu)

Imunopatologie? … a co my s tím???
Autoři: doc. MUDr. Helena Lahoda Brodská, Ph.D.

Všechny kurzy
Kurzy Podcasty Doporučená témata Časopisy
Přihlášení
Zapomenuté heslo

Zadejte e-mailovou adresu, se kterou jste vytvářel(a) účet, budou Vám na ni zaslány informace k nastavení nového hesla.

Přihlášení

Nemáte účet?  Registrujte se

#ADS_BOTTOM_SCRIPTS#