Obama health care for all americans: practical implications
From: Pain Physician. 2009 Mar-Apr;12(2):289-304
Rapidly rising health care costs over the decades have prompted the application of business practices to medicine with goals of improving the efficiency, restraining expenses, and increasing quality. Average health insurance premiums and individual contributions for family coverage have increased approximately 120% from 1999 to 2008. Health care spending in the United States is stated to exceed 4 times the national defense, despite the wars in Iraq and Afghanistan. The U.S. health care system has been blamed for inefficiencies, excessive administrative expenses, inflated prices, inappropriate waste, and fraud and abuse. While many people lack health insurance, others who do have health insurance allegedly receive care ranging from superb to inexcusable. In criticism of health care in the United States and the focus on savings, methodologists, policy makers, and the public in general seem to ignore the major disadvantages of other global health care systems and the previous experiences of the United States to reform health care. Health care reform is back with the Obama administration with great expectations. It is also believed that for the first time since 1993, momentum is building for policies that would move the United States towards universal health insurance. President Obama has made health care a central part of his domestic agenda, with spending and investments in Children’s Health Insurance Program (CHIP), American Recovery and Reinvestment Act of 2009, and proposed 2010 budget. It is the consensus now that since we have a fiscal emergency, Washington is willing to deal with the health care crisis. Many of the groups long opposed to reform, appear to be coming together to accept a major health care reform. Reducing costs is always at the center of any health care debate in the United States. These have been focused on waste, fraud, and abuse; administrative costs; improving the quality with health technology information dissemination; and excessive regulations on the health care industry in the United States. Down payment on health care reform, American Recovery and Reinvestment Act, and CHIP include many provisions to reach towards universal health care.
(more…)
Association of tinnitus and electromagnetic hypersensitivity: hints for a shared pathophysiology?
From: PLoS ONE. 2009;4(3):e5026. Epub 2009 Mar 27
Tinnitus is a frequent condition with high morbidity and impairment in quality of life. The pathophysiology is still incompletely understood. Electromagnetic fields are discussed to be involved in the multi-factorial pathogenesis of tinnitus, but data proofing this relationship are very limited. Potential health hazards of electromagnetic fields have been under discussion for long. Especially, individuals claiming themselves to be electromagnetic hypersensitive suffer from a variety of unspecific symptoms, which they attribute to electromagnetic fields exposure. The aim of the study was to elucidate the relationship between electromagnetic field exposure, electromagnetic hypersensitivity and tinnitus using a case-control design.
Tinnitus, the perception of sound in the absence of an external sound, is a frequent disorder of auditory perception, which is very difficult to treat. Tinnitus as a phantom perception of a meaningless sound has to be differentiated from auditory hallucinations which mainly occur in the context of psychiatric diseases and are characterized by e.g. the perception of voices. About 10–20% of the adult population experiences some degree of tinnitus. Many learn to ignore the sounds and experience no major effects, but for about 1 in 100 adults, the noise interferes significantly with daily life. In those patients, tinnitus is frequently associated with neuropsychiatric co-morbidity such as depression, anxiety or sleep disorders, which underlines the clinical and socio-economic importance.
Even if the pathophysiology of tinnitus remains incompletely understood, there is growing evidence that dysfunctional neuroplastic processes in the brain are involved. In particular, it is assumed that tinnitus might be the correlate of maladaptive neuroplastic changes due to distorted sensory input. Accordingly functional imaging studies demonstrated neuroplastic alterations in the central auditory system. However tinnitus related alterations of neural functioning are not limited to the central auditory system, but also encompass non-auditory regions such as frontal and limbic areas.
(more…)
Effects of at-work exercises on computer operators
From: Work 28 (2007) 67–75
At-work exercises are commonly recommended for computer operators. This randomized control trial assessed adherence, pain and satisfaction after 4 weeks of at-work exercise. Subjects (n = 72) were randomized into 3 groups: resistance exercise, stretching, and control. Outcomes included a satisfaction survey, a visual analogue pain scale, a pain drawing, and the Neck Disability Index. The Visual Analog Scale, the drawing, and Neck Disability Index were analyzed together as a composite variate referred to as Pain Impact. Exercise frequency was similar across the 3 groups (median = 1.5 times per day). No differences were found between groups on Pain Impact or individual pain variables. Most satisfaction survey item scores did not differ between groups. However, a significant difference between groups on the survey item related to discomfort. The resistance and stretching group differed from the control group with regard to their perception that the exercises were helpful in reducing discomfort in the back and neck. We conclude that most subjects found the resistance and the stretching exercises easy to do, performed them 1 to 2 times daily, and said they reduced discomfort. To determine optimal type and frequency of at-work exercises, further study is needed.
Concurrent with increasing use of video display terminals, an alarming incidence of musculoskeletal disorders associated with computer use has been reported. A study of neck/shoulder discomfort prevalence in video display terminals operators found that 61.5% experienced some discomfort and 7.5% experienced intense discomfort. Other authors have reported that 27% of video display terminals operators experience almost constant neck discomfort, and 30% experience frequent pain. Gerr et al. found that more than 50% of computer operators reported musculoskeletal symptoms over a 3 year period. In computer operators, the cervical region is reported to be the most commonsite of musculoskeletal pain.
The development of musculoskeletal pain or discomfort in computer operators is theorized to be multifactorial, and includes occupational, ergonomic, psychological, psychosocial, and demographic parameters. Occupational and ergonomic factors include workstation design, task diversity, work/task demands, rest cycles, and posture. Marcus et al. found that postural factors were associated with upper quarter musculoskeletal symptoms in computer operators. A review of epidemiological studies concluded that posture is an independent risk factor for development of work related musculoskeletal disorders among computer users. Constrained, prolonged, or static postures lead to undesirable EMG muscle activity and discomfort. Infrequent postural changes and presence of discomfort while sitting are predictive of musculoskeletal problems. Self-reported exposures to mouse and keyboard use have been shown to predict elbow, wrist and hand symptoms in computer operators. The number of hours spent performing keyboard operation appears to be a risk factor for work related musculoskeletal disorders.
(more…)
Sedentary lifestyle as a risk factor for low back pain: a systematic review
From: Int Arch Occup Environ Health. 2009 Mar 20. [Epub ahead of print]
To review systematically studies examining the association between sedentary lifestyle and low back pain using a comprehensive definition of sedentary behaviour including prolonged sitting both at work and during leisure time. Journal articles published between 1998 and 2006 were obtained by searching computerized bibliographical databases. Quality assessment of studies employing a cohort or case-control design was performed to assess the strength of the evidence.
Low back pain is a common musculoskeletal problem that affects most people at some point in their lifetime. Slow recovery in some individuals with low back pain can impact on the person’s physical and psycho-social functions and increase the socio-economic burden. In contextual concepts of the International Classification of Functioning, Disability and Health (ICF) model, both environmental and individual factors affect the development of lolw back pain. Lifestyle is a factor that could affect an individual’s health. Sedentary lifestyle is associated with obesity, which in turn is linked to chronic health problems. Modern living increases the tendency to have a more sedentary lifestyle that involves sitting. From a biomechanical perspective, sitting is an easy and more stable posture with low-energy consumption, lower centre of mass and larger base of support.
Using pre-determined keywords, the authors identified 1,778 titles of which 1,391 were considered irrelevant. Then, 20 of the remaining 387 publications were scrutinized for full review after an examination of all the 387 abstracts. Finally, 15 studies (10 prospective cohorts and 5 case-controls) were included in the methodological quality assessment, of which 8 (6 cohorts and 2 case-controls; 53%) were classified as high-quality studies. One high-quality cohort study reported a positive association, between low back pain and sitting at work only; all other studies reported no significant associations. Hence, there was limited evidence to demonstrate that sedentary behaviour is a risk factor for developing low back pain. The present review confirms that sedentary lifestyle by itself is not associated with low back pain.
Chronic tension type headache: what is new?
From: Curr Opin Neurol. 2009 Mar 18. [Epub ahead of print]
This review discusses current data on nosological boundaries related to diagnosis, pathophysiology and therapeutic strategies in chronic tension type headache. Diagnostic criteria of chronic tension type headache should be adapted to improve its sensitivity against migraine. It seems that mechanical pain sensitivity is a consequence and not a causative factor of chronic tension type headache. Recent evidence is modifying previous knowledge about relationships between muscle tissues and chronic tension type headache, suggesting a potential role of muscle trigger points in the genesis of pain. An updated pain model suggests that headache perception can be explained by referred pain from trigger points in the craniocervical neck muscles, mediated through the spinal cord and the trigeminal nucleus caudalis rather than only tenderness of the neck muscles themselves.
Different therapeutic strategies for chronic tension type headache; pharmacological, physical therapy, psychological and acupuncture, are generally used. The therapeutic efficacy of nonsteroidal anti-inflammatory drugs remains incomplete. The tricyclic antidepressants are the most used first-line therapeutic agents for chronic tension type headache. Surprisingly, few controlled studies have been performed and not all of them have found an efficacy superior to placebo. Further, there is insufficient evidence to support or refute the efficacy of physical therapy in chronic tension type headache. Although there is an increasing scientific interest in chronic tension type headache, future studies incorporating subgroups of patients who will likely to benefit from a specific treatment (clinical prediction rules) should be conducted.
In Eur J Pain. 2007 May;11(4):475-82, it was noted that referred pain from trapezius muscle trigger points shares similar characteristics with chronic tension type headache. The results showed that manual exploration of trigger points in the upper trapezius muscle elicited referred pain patterns in both chronic tension type headache patients and healthy subjects. In chronic tension type headache patients, the evoked referred pain and its sensory characteristics shared similar patterns as their habitual headache pain, consistent with active trigger points.
In Pain Med. 2009 Jan;10(1):43-8, referred pain elicited by manual exploration of the lateral rectus muscle in chronic tension type headache. In some patients with chronic tension type headache, the manual examination of lateral rectus muscle trigger points elicits a referred pain that extends to the supraorbital region or the homolateral forehead. Nociceptive inputs from the extraocular muscles may sustain the activation of trigeminal neuron, thus sensitizing central pain pathways and exacerbating headache.
According to Headache. 2007 May;47(5):662-72, Active trigger points in the upper trapezius, sternocleidomastoid, and temporalis muscles were more common in tension headache subjects than in healthy controls, although trigger point activity was not related to any clinical variable concerning the intensity and the temporal profile of headache, tension headache patients showed greater forward head posture and lesser neck mobility than healthy controls, although both disorders were not correlated with headache parameters.
Frequency and interrelations of risk factors for chronic low back pain in a primary care setting
From: PLoS ONE. 2009;4(3):e4874. Epub 2009 Mar 16
General practitioners are often consulted for low back pain. The point prevalence of low back pain is reported to be about 15% to 30% in the Western world. For about 6% to 10% of patients, the disease may recur or become chronic and the demand on the health-care system is great and costly. These patients are also a cause of major disability and absence from work. Fewer than half of individuals disabled for longer than 6 months return to work, and after 2 years of absence from work, the return-to-work rate is close to zero. Moreover, back pain is the most common chronic illness in subjects younger than 65 years.
Early identification of risk factors for chronic low back pain is important in understanding and preventing the progression to chronic disease and disability.
Many studies in Western industrialized countries have attempted to identify risk factors for low back pain, with a good evidence of relation between chronic low back pain and history of low back pain (including pain severity, duration, disability, leg pain, related sick leave and history of spinal surgery), low level of job satisfaction and poor general health. Only moderate evidence exists for a relation between chronic low back pain and psychosocial factors such as employment status, amount of wages, workers’ compensation, and depression or physical factors such as lifting time per day and work posture.
The literature on risk factors for chronic low back pain is abundant with numerous prospective studies done on relatively small samples of patients assessing only a specific category of chronic low back pain risk factors. Moreover, the major drawback in prospective and cross-sectional studies of chronic low back pain risk factors is the use of simplistic methodological approach without considering the interrelations of the known risk factors. These studies do not allow for analyzing the structure of the existing relations between risk factors and discovering the underlying dimensions explaining the links between risk factors.
(more…)
Psychological factors and domains of neck pain disability
From: Pain Med. 2009 Mar;10(2):310-8
This study evaluated the relationship between psychological distress and disability associated with neck pain, analyzed the Neck Disability Index for disability factors, and assessed the impact of psychological distress on those domains of disability in a prospective cross-sectional analytic survey.
Outpatient physical therapy clinic. Sixty-one consecutive adult subjects with dominant neck pain participated. Each subject completed the Neck Disability Index, psychometric measures for the Distress Risk Assessment Method, and a numeric pain rating scale.
Measures of depression, somatization, and pain intensity explained 60% of the variance of disability due to neck pain. Factor analysis revealed two disability factors in the Neck Disability Index dealing with physical activity/participation limitations and nonphysical activity related impairments in bodily function. Psychological distress and pain intensity explained 25.6% of the variance of the factor dealing with activity/participation limitations, and 53.5% of the variance for the factor associated with impairments in bodily functions.
Nondistressed adults reported significantly less disability due to neck pain than psychologically distressed subjects. The Neck Disability Index was found to contain two factors that pertain to three domains of the disability. Five items relating to impairments in bodily function strongly correlated with depression and somatization. Presence of psychological distress has a confounding effect on Neck Disability Index scores. An outcome measure containing items related only to activity limitations and participation restrictions might give a truer picture of disability associated with neck pain for patients with psychological distress.
Neck pain
From: Med Clin North Am. 2009 Mar;93(2):273-84
Neck pain due to cervical spine and related disorders, although not as common as low back pain, is nonetheless a common and often debilitating problem and an important reason for seeking medical attention. Although patients with neck pain secondary to trauma may be seen initially in an emergency department or in some cases by a specialist, such as an orthopedic surgeon, neck pain more often is spontaneous in onset without correlation with a specific activity or neck trauma. Patients with neck pain frequently see their primary care physician first, which is most appropriate given that many of these patients can be treated effectively without extensive diagnostic testing or referral to a specialist. It is important that the generalist have a good working knowledge of how to evaluate patients with neck pain and the differential diagnosis of disorders of the neck. It is also important to remember that patients presenting with neck and shoulder pain, particularly when it extends into the upper extremities, may have disorders of the brachial plexus rather than a cervical radiculopathy.
Although the approach to history taking for neck pain is similar in many respects to that for low back pain there are enough differences to warrant a separate discussion. Patients with cervical disorders of one type or another may present with lower extremity and bladder or bowel symptoms often with only minimal neck pain. It is important in patients with suspected neck disorders to ask about symptoms referable to lower extremities as well as bladder and bowel functions. This can include questions about the presence of paresthesia in the lower extremities, weakness of the lower extremities, gait disorders, impotence in men, and anorgasmia in women along with bladder disturbances. Sometimes differentiating a peripheral neuropathy, cauda equina syndrome, and cervical myelopathy on the basis of the history is more difficult that one might suspect.
(more…)
