From: Clin Invest Med. 2009 Oct 1;32(5):E360-7

Chronic low back pain is one of the main causes of disability in the community. Although there have been studies suggesting an association between smoking and chronic low back pain, these studies were limited by the small numbers of patients, and they did not control for confounders. The objective of this study was to determine whether cigarette smoking is associated with an increased risk of chronic low back pain among adults.

Using Canadian Community Health Survey (cycle 3.1) data, 73,507 Canadians aged 20 to 59 yr were identified. Self-reported chronic low back pain status, smoking habits, sex, age, height, weight, level of activity and level of education were identified as well. Back pain secondary to fibromyalgia was excluded. Multivariate logistic regression analysis was used to detect effect modification and to adjust for covariates. Design effects associated with complex survey design were taken into consideration.

The prevalence of chronic low back pain was 23.3% in daily smokers and only 15.7% in non smokers. Age and sex were found to be effect modifiers, and the relationship between smoking and chronic low back pain risk was dependent on sex and age. The association between daily smoking and the risk of chronic low back pain was stronger among younger individuals. Occasional smoking slightly increased the odds of having chronic low back pain.

Daily smoking increases the risk of chronic low back pain among young adults, and this effect seems to be dose dependent. Back pain treatment programs may benefit from integrating smoking habit modification. Further research is required to develop effective prevention strategies.

From: Public Health. 2009 Aug 24

Examination of the prevalence, correlates and prospective impact of musculoskeletal pain on physical and psychological function in a population health survey of elderly Chinese men and women. Four thousand men and women, aged 65 years and over, living in the community in Hong Kong took part in this study. A questionnaire to determine demographics, socio-economic status, medical history, smoking, alcohol intake and level of physical activity was administered by an interviewer. Participants were asked about the presence of pain in the back, neck, hip and knee in the past 12 months. They were re-interviewed after 4 years of follow-up to document physical performance measures, psychological function and occurrence of falls, fractures and mortality.

Overall, back pain was most prevalent (48%), followed by knee (31%), neck (22.5%) and hip (8.9%) pain; the values was nearly twice as high in women compared with men for all sites. The presence of pain was not correlated with age, but was associated with various measures of socio-economic status as well as comorbidities. Baseline prevalence of pain was related to physical performance and quality-of-life measures, and fracture incidence after 4 years of follow-up.

Musculoskeletal pain is prevalent among elderly men and women, being much higher in the latter, giving rise to considerable functional and psychological impairments. Osteoporosis and osteoarthritis are likely to be the main underlying causes. The condition may be considered part of the frailty syndrome, and in this context, prevention and management represent major public health challenges.

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.

Rapidly rising health care costs over the decades have prompted the application of business practices to medicine with goals of improving efficiency, restraining expenses, and increasing quality. Further, concern about escalating costs and the quality of health care delivered in the United States has led to an increase in focus on pay-for-performance, value-driven health care, and public reporting of quality and cost information. At the same time, employers fear cost of health insurance and individuals are also worried about soaring health care costs. Average health insurance premiums and worker contributions for family coverage. The employer contribution has soared from $4,247 in 1999 to $9,325 in 2008 with a 119% increase. During the same period employee contributions have increased from $1,543 to $3,354 in 2008 at 117% increase. Total expenses increased from $5,791 to $12,680 a 119% increase.

It has been quoted that health care spending is 4.3 times that for national defense, despite the wars in Iraq and Afghanistan. Further, our 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.

It was shown that per capita spending in the United States is the highest among Organisation for Economic Co-operation and Development (OECD) countries. The expenditures per capita in the United States were $5,635 on health care in 2003, whereas based on the analysis it should be $3,990 per capita. Consequently, the United States spent $1,645 per capita more than would have been expected. In absolute terms, the highest discrepancy was noted in hospital care of $224 billion, followed by outpatient care of $178 billion. However, the largest discrepancy was the category of administration of health care system, on which the United States spends 6 times more per capita than its peer countries ($412 versus $72) almost a quarter of excess spending in the United States.

In contrast, in 2006 the United States spent nearly $650 billion more on health care than peer OECD countries, even after adjusting for health. Of this amount, outpatient care, which includes same-day hospital visits and is by far the largest and fastest growing part of the U.S. health system. Four other cost categories – drugs; health administration and insurance; investment in health; and inpatient care – are responsible for $279 billion in spending above expected. In the remaining 2 categories of long-term and home care and durable medical equipment U.S. spending is $72 billion less than expected. Consequently, U.S. health spending totalled $2.1 trillion in 2006, an increase of $363 billion since 2003, and total nearly $6,800 per capita.

Outpatient care accounts for more than 40% of the overall health care spending and 68% of spending, expanding at 7.5% per annum from 2003 to 2006 – a faster pace of growth than observed in any other cost category – adding more than $166 billion in costs during this period. Same-day hospital care accounts for $245 billion, physician office visits account for $392 billion, and ambulatory surgery centers and diagnostic imaging centers contributed to $28 billion. However, same-day hospital care is the fastest growing of all outpatient cost categories at 9.3% per year.

Drugs account for 12% of overall health care costs and 15% of total spending above expected ($98 billion), growing 6.9% annually from 2003 to 2006, resulting in a $45 billion increase in costs. These increases are due to 3.5% a year prescription growth and 4.5% net price growth and a more expensive drug mix. However, it appears that the United States on average uses 10% fewer drugs per capita than other OECD countries, whereas prices are 50% higher than those in other countries for equivalent drugs.

Provider groups believe that outlandish administrative costs represent one of the biggest problems with our health care system. These costs accrue from insurers, both public and private, from medical groups and hospitals. Administrative expenses account for about 30% of the total costs of the health care in the United States. That translates to approximately $680 billion of $2.3 trillion spent in 2007 or $7,421 spent per person.

In fact, the study by McKinsey Global Institute shows that health administration and insurance expense category accounts for 7% of overall health care costs and 14% of total spending above expected ($91 billion), spending growing by 6.3% annually over the 3-year period, resulting in a $25 billion increase in costs. However, it appears that this report grossly underestimates administrative costs. Further, this report also shows that the administrative costs for Medicare enrollee grew by nearly 30% per year, which largely reflected payouts to private administrators or Medicare advantage plans and the Part D drug benefit. From 2005 to 2006 alone, administration for all Medicare programs increased by nearly $8 billion.

McKinsey Global Institute report shows that long-term and home care accounts for 9% of overall health care costs, but is $53 billion less than expected, reducing total spending by 8%. Even then, the report shows that from 2002 to 2006, this category grew by 6.2% annually, resulting in a $30 billion increase in costs. In contrast, a recent Government Accountability Office (GAO – 09 – 185) report shows that fraud and abuse helped boost Medicare spending on home health services 44% over 5 years as some providers exaggerated patients medical conditions and others billed for unnecessary services or care they did not provide. The GAO reviewed home care payments from 2002 to 2006, when spending reached $13 billion. Continuing with the increasing trend, during the past year, Medicare spent about $16.5 billion on home care for the services reviewed by the GAO out of the total budget of $455 billion.

“Change is in the air,” we have heard this on many, many occasions. There is always too much talk and very little action. Starting with Harry Truman in the 1940s, Richard Nixon in the 1970s, and Bill Clinton in the 1990s, all of them attempted change in the health care system and enacted some kind of national health insurance. Other health care mavericks such as Representative Stark bill with his calling for greater reliance on the government than the Clinton plan also failed. In addition, Representative Cooper’s plan with a bipartisan group of 80 representatives representatives in support of a more market-friendly plan, and Senators Breaux and Durenberger similar plan in the Senate also failed.

Health care reform is back with the Obama administration with great expectations. It is 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, coupled with promises from key members of Congress to introduce ambitious health care reform legislation in 2009 and nomination of Governor Kathleen Sebelius as secretary-designate of the United States Department of Health and Human Services (DHHS).

In May 2006, former Senate majority leader, Tom Daschle (the first nominee for secretary designate for DHHS — nomination withdrawn 2/3/2009), prophetically said that it may take a major fiscal emergency to make Washington deal with the health care crisis. Further, there is growing sentiment that the prospects for meaningful health care reform have never looked better. As many of the groups long opposed to reform, including the insurance industry and physician groups, are reportedly prepared to make a deal — willing to accept radical surgery. In fact, a budget for change has been proposed with down payment in health care reform.

However, Obama’s ambitious plan is not without criticism and negativity. The Obama plan has been described as more regulation with unsustainable spending. Further, Obama’s health plan is considered ambitious in any economy, but more so in present economy. The majority of the physicians have a negative view on Obama’s health plan.

While health care reform is not only essential but also mandatory, creation of a huge bureaucracy may not achieve the goals of increasing efficiency, improving the quality, and reducing the costs resulting in universal coverage. It would be ideal to study the effectiveness or lack thereof of the UK’s health care system, NICE, the demise of AHCPR, and the effectiveness of AHRQ.

Apart from the economic crisis, we will be watching, with great interest, the health care reform. It has been stated that the Obama administration’s chief of staff prior to taking office, remarked, “you never want a serious crisis to go to waste,” implying that the economic crisis has allowed the Obama administration to undertake far-reaching health care initiatives that it could not otherwise have launched quickly, if at all . However, now the government, public, and providers will have to determine how the reform will effect the health care system of the United States — is it radicular surgery, cosmetic surgery, or surgery gone bad.

A national study among 526 primary care physicians revealed that the majority (61%) reported that health care delivery will “get worse” in the next four years, after viewing video segments from President Obama’s speech to Congress. The study was conducted by HCD Research during February 26-27 to obtain physicians’ perceptions on President Obama’s new health care reform plan that was outlined in his speech to Congress on February 24, 2009. Nearly half (49%) of respondents indicated that skepticism was the emotion they felt most while watching President Obama outline his new health care reform plan. When asked how they thought their professional life would change in four years, the majority (64%) thought it would get worse.

From: Int J Circumpolar Health. 2008 Jun;67(2-3):279-87

To identify health problems among workers performing cleaning, maintenance and machine operation tasks inside cold storage rooms with temperatures between -43 degrees C and -62 degrees C in a freeze drying coffee company. All 24 workers working inside the cold stores participated in the study. A questionnaire about cold related health problems and the standardized Nordic questionnaire assessing muscle complaints were completed by all exposed workers. A physical examination was performed on each worker.

The most relevant cold related health problem was episodic finger symptoms (50%), followed by respiratory symptoms (21%), peripheral circulation symptoms (20%), and repeated pain in the musculoskeletal system (12%). Two subjects had a previous diagnosis of Raynaud’s phenomenon. The prevalence of musculoskeletal complains in the neck and low back was 21% in each. The prevalence found for various complaints among the freeze drying coffee workers implies that the cold conditions inside cold stores may present a real risk of cold related health problems and, due to lowered concentration level, for injuries, too. Greater efforts should be made to minimize the cold exposure by designing automation processes to prevent continuous exposure to cold during freeze drying process. In addition, improving the cold protective clothing and guaranteeing its appropriate use will reduce health risks.

From: Spine. 2008 Aug 15;33(18):1982-5

All terrain vehicles are associated with a higher incidence of axial compression and burst-type fracture morphologies. Although relatively safe and enjoyable when used properly, all terrain vehicles are associated with thousands of spinal injuries each year.

All terrain vehicles are currently experiencing enormous popularity in the United States. It has been estimated that there are currently over 7 million all terrain vehicles being operated at the present time in America. Although many drivers never get injured, All Terrain Vehicles have accounted for approximately 68,000 injuries and 270 deaths per year since 1985. In 2004 alone, injuries associated with all terrain vehicles use and misuse lead to 136,100 emergency room visits and 767 fatalities.

In 1988, an agreement was reached between the federal government and all terrain vehicle manufacturers that limited the production and sale of all terrain vehicles to only the 4-wheel or quad variety. This decree as well as state legislated helmet use has led to a decrease in the mortality rate. However, to date, there are only 21 states which mandate the use of helmets and other safety equipment. It has been shown in 2001, that in states without helmet laws, there is a 2-fold increase in all terrain vehicle related mortalities.

There have been numerous studies showing a correlation between driver experience and injuries associated with the use of all terrain vehicles. Some of these studies estimate that children under the age of 16 account for nearly 40% of all all terrain vehicle related injuries. Inexperience is just 1 identifiable risk factor. Alcohol intoxication and excessive speed as additional risk factors associated with all terrain vehicle accidents. Our study confirms these as risk factors for recreational use all terrain vehicle related injuries. In addition to driver impairment secondary to intoxication, excessive speeding, and driver inexperience, we also observed that use of these vehicles after dark was a frequent factor associated with vehicle roll over in this patient population.

Many authors have made suggestions to try to improve all terrain vehicle safety. There are some absolute recommendations that can be made in an attempt to reduce all terrain vehicle related injuries.

1. All individuals purchasing an all terrain vehicle should first be required to pass both a written and practical examination, where they can demonstrate a minimum amount of driving proficiency and safety.

2. There should be a minimal age requirement for obtaining the aforementioned license, similar to an automobile driver’s license. A limited license or permit may be issued to drivers under the age limit, who demonstrate a minimum amount driving proficiency and safety. This is similar to the requirements of some states for use of a personal recreational watercraft.

3. Every state should require the use of helmets and associated safety equipment of every driver of an all terrain vehicle.

In addition to these, there are some general guidelines that should be followed when operating these vehicles.

1. Never operate an all terrain vehicle while under the influence of any substance that may limit ones ability to mentally or physically control the vehicle.

2. Never operate the vehicle at times of the day or in areas where trails or paths cannot be well visualized because of darkness or shrub, tree, or obstacle interference.

3. Never operate vehicles at an unsafe or excessive speed.

4. Never allow anyone with little or no experience to operate the vehicle in an unsupervised or unassisted manor.

Although some of these may seem simple and obvious, this study clearly shows that these are not being followed. The United States government echoes these safety recommendations on their website, which can be found at: ATVSafety.gov.

While identifying certain associated risk factors, we were also able to better define the types of spinal cord injuries associated with all terrain vehicle accidents. All of our radiographically identified injuries can be classified according to the Denis classification, by injury morphology, as either axial compression versus burst injuries or as distraction type injuries. These types of morphologies are typically seen when the driver is either thrown from the vehicle or when the vehicle rolls over the driver pinning him/her against the ground. Approximately two third of the injuries occurred in the thoracolumbar spine, whereas the other one third occurred in the cervical spine. The trauma or emergency team treating a patient involved in an all terrain vehicle accident must have a high index of suspicion for these associated spine injuries.

Although limited by the retrospective nature of the study design, this study has been able to identify certain high risk behaviors leading to all terrain vehicle accidents and related injuries. Common spinal injury patterns have been demonstrated. In addition, some specific safety recommendations have been made. All terrain vehicles although highly dangerous leading to death or serious injury can be fun, enjoyable, and safe if proper regulations and safety precautions are followed.

From: Journal of Human Hypertension (2007), 1–6

It is well known that achievement of blood pressure goals in more than 70% of hypertensive individuals requires two or more antihypertensive agents. Based on the most recent NHANES 1999– 2000 data, blood pressure control in the US has not improved significantly. Moreover, many people have searched for alternative methods for lowering arterial pressure.

Since the early 1940s, a small cadre of chiropractic specialists have foregone typical ‘full-spine manipulations’, limiting their practice to precise, delicate manual alignment of a single vertebra, C-1 or Atlas; these practitioners make up the National Upper- Cervical Chiropractic Association (NUCCA). Unlike other vertebrae, which interlock one to the next, the Atlas relies solely upon soft tissue (muscles and ligaments) to maintain alignment; therefore, the Atlas is uniquely vulnerable to displacement. Displacement of C-1 is pain free and thus, remains undiagnosed and untreated, whereas health-related consequences are attributed to other aetiologies.

Minor misalignment of the Atlas vertebra can potentially injure, impair, compress and/or compromise brainstem neural pathways. The relationship between hypertension and presence of circulatory abnormalities in the area around the Atlas vertebra and posterior fossa of the brain has been known for more than 40 years. Studies by Jannetta et al. note arterial compression of the left lateral medulla oblongata by looping arteries of the base of the brain in 51 of 53 hypertensive patients who underwent left retromastoid craniectomy and microvascular decompression for unrelated cranial nerve dysfunctions. Such compression was not present in normotensive patients. Treatment by vascular decompression of the medulla was performed in 42 of the 53 patients and amelioration of hypertension was noted in 76%.6 Moreover, studies to clarify the mechanism by which decompression of the left rostral ventrolateral medulla relieves neurogenic hypertension are summarized in a review. It is clear from these studies that a sub-population of hypertensive patients improved their blood pressure after microvascular decompression.

Changes in the anatomical position of the Atlas vertebra and resultant changes in the circulation of the vertebral artery lend itself to worsening of hypertension. Recent studies by Akimura et al. using magnetic resonance (MR) imaging examined hypertensive patients and compared them to controls, evaluating the relationships between the upper ventrolateral medulla and vertebral arteries and branches. They noted compression in 90.6% of 32 hypertensive cases, this was in contrast to controls and those with secondary hypertension who failed to demonstrate a significant incidence of compression. Furthermore, two other studies using MR imaging techniques also demonstrated a significant association between compression of the vertebral artery and changes in the posterior fossa of hypertensive but not normotensive individuals. Thus, alterations in Atlas anatomy can generate changes in the vertebral circulation that may be associated with elevated levels of blood pressure.

This pilot study examines the relationship between nonsurgical interventions to align the Atlas vertebra and long-term changes in blood pressure and heart rate. The criteria used in this study to establish efficacy of an antihypertensive effect are those defined by the Food and Drug Administration for approval of a new antihypertensive drug. Specifically, it would require a blinded design with a placebo-subtracted reduction in diastolic blood pressure of 5mm Hg or more and be free of serious side effects to be approvable.

The findings of this pilot study represent the first demonstration of a sustained blood pressure lowering effect associated with a procedure to correct the alignment of the Atlas vertebra. The improvement in blood pressure following the correction of Atlas misalignment is similar to that seen by giving two different antihypertensive agents simultaneously. Moreover, this reduction in blood pressure persisted at 8 weeks and was not associated with pain or pain relief or any other symptom that could be associated with a rise in blood pressure.

Other studies support the notion that changes in the cerebral circulation that is related to the position of the Atlas vertebra can affect blood pressure. Coffee et al. reviewed MR images and demonstrated a significant association between pulsatile arterial compression of the ventrolateral medulla and presence of hypertension. They concluded that subjects with hypertension should have an evaluation of their posterior fossa for evidence of anatomic abnormalities. In fact, data linking changes in Atlas anatomy and posterior fossa circulatory changes associated with hypertension date back more than 40 years and are reviewed by Reis.

The mechanism as to why this improvement in blood pressure occurs is unknown and cannot be determined by this study. What is clear is that a significant change in sympathetic tone is probably not a major contributing mechanism as heart rate was not significantly changed. The data presented, however, raises a number of important questions including: (a) how does misalignment of C1 affect hypertension? (b) If there is a cause and effect relationship between C1 misalignment and hypertension is malposition of C1 an additional risk factor for the development of hypertension?

What is clear is that misalignment of the Atlas vertebra can be determined by assessment of the alignment of the pelvic crests. This should be considered in those who have a history of hypertension and require multiple medications for treatment. Additionally, it should be considered in those with refractory hypertension and a history of neck injuries, independent of the presence of pain. Note that pain was not present in any of the patients randomized in this study.

From: Otolaryngology Head and Neck Surgery 2008 Apr;138(4):479-85

Present experience in diagnosis and treatment for referred otalgia secondary to cervical spine degenerative disease.

A study of 123 patients with ear pain. All patients had a normal otologic examination and diagnosed with unspecified otalgia. The causes for referred otalgia were categorized into Group I: otalgia from non-cervical spine disease (n = 72), and Group II: cervical spine disease-referred otalgia (n = 51). Pain relief following cervical spine physical therapy was assessed.

The most common cause for referred otalgia in Group I was Temporomandibular joint (TMJ) dysfunction (46%); most common cervical spine finding in Group II was cervical spine degenerative disease (88%). Cervical spine physical therapy in those documented patients all reported subjective pain relief.

As the population in America ages, cervical spine degenerative disease in the elderly will begin to emerge as a major etiologic source for referred otalgia. With a targeted medical history and physical examination one can use directed studies to diagnose cervical spine degenerative disease-referred otalgia, and this pain can be alleviated with cervical spine physical therapy.

From: Journal of Athletic Training. 2004 Jul–Sep; 39(3): 278–279

Based on the available evidence, cryotherapy seems to be effective in decreasing pain. In comparison with other rehabilitation techniques, the efficacy of cryotherapy has been questioned. The exact effect of cryotherapy on more frequently treated acute injuries (eg, muscle strains and contusions) has not been fully elucidated. Additionally, the low methodologic quality of the available evidence is of concern. Many more high-quality studies are required to create evidence-based guidelines on the use of cryotherapy. These must focus on developing modes, durations, and frequencies of ice application that will optimize outcomes after injury.

We often recommend ice for neck pain relief, usually for whiplash injuries, however, I find many patients do not tolerate cryotherapy on the neck well, especially in colder climates. It would be interesting to see some actual studies comparing cryotherapy to a more traditional martial arts approach using a properly designed liniment with light massage on recovery from soft tissue injuries.

The effects of ice have been demonstrated in numerous animal models and human studies. Ice reduces tissue temperature, blood flow, pain, and metabolism. However, and possibly more important, is the question, “Does ice application improve the treatment outcomes?” Does treatment facilitate achievement of goals related to functional limitations and sudden transient disability after injury or surgery? Bleakley et al reported that cold seemed to be more effective in limiting swelling and decreasing pain in the short term (immediately after application to 1 week postinjury). However, the long-term effects of cryotherapy and the effect on the tissue repair are not known. Only 1 group examined the effect of cryotherapy at 4 weeks postinjury. Additionally, evidence is limited that cryotherapy hastens return to participation.

Currently, only 4 groups have examined the effect of cryotherapy on return to participation. The 4 groups addressed return to sport or work after ankle sprain and scored 2–4 on the PEDro scale (maximum = 10 points). Cryotherapy was applied immediately after injury. Two of the four reports suggested that cryotherapy speeds return to full activity. However, the results of the outcome measures were not fully documented. A confounding factor of compression as part of the treatment prevents interpretation of the effects of cryotherapy in one of the articles. Therefore, whether cryotherapy facilitates return to participation is still unclear.

Ice does not seem to be more effective than compression after surgery. Only 2 of the 8 groups reported significant differences in favor of ice and compression. However, in all 8 studies, postsurgical dressings or socks were used to separate the injured area of the body and the cooling agent. Such barriers may have mitigated the cooling effect of the cold compress. Further research comparing ice with compression is required in subjects with acute injuries.

Currently, no authors have assessed the efficacy of ice in the treatment of muscle contusions or strains. Considering that most injuries are muscle strains and contusions, this is a large void in the literature. Most cryotherapy studies have focused on postsurgical anterior cruciate ligament repairs and knee and hip replacements. The results of these studies cannot be generalized to muscle strains and contusions.

The Bleakley et al study has several limitations. In the 12 treatment comparisons made by Bleakley et al, only 1 or 2 articles were examined in some instances. It is difficult to generalize results based on only 1 or 2 studies. Additionally, the authors did not separate cryotherapy for acute immediate care from that for rehabilitation. The goals for each may be different and a potential reason for the lack of efficacy of cryotherapy.

Based on this review by Bleakley et al and a similar review by Hubbard et al, the methodologic quality of clinical trials of cryotherapy is poor. Most of the studies were conducted years ago. Additionally, with cryotherapy research, it is not possible to blind subjects to the exposure to cold and thus score 10 on the PEDro scale. However, scores higher then 5 should be achieved. Assessing the quality of the randomized, controlled clinical trials is important because of evidence that low-quality studies provide biased estimates of treatment effectiveness. Despite the general acceptance of cryotherapy as an effective intervention, evidence on which to base these conclusions is limited. Only with strong randomized, controlled clinical trials will we know the true efficacy of cryotherapy.

Specific search criteria identified 55 articles for review, of which 22 were eligible randomized, controlled clinical trials. The articles’ scores on the PEDro scale were low, ranging from 1 to 5, with an average score of 3.4. Five studies provided adequate information on the subjects’ baseline data, and only 3 studies concealed allocation during subject recruitment. No studies blinded their therapist’s administration of therapy, and just 1 study blinded subjects. Only 1 study included an intention-to-treat analysis. The average number of subjects in the studies was 66.7; however, only 1 group undertook a power analysis. The types of injuries varied widely (eg, acute or surgical). No authors investigated subjects with muscle contusions or strains, and only 5 groups studied subjects with acute ligament sprains. The remaining 17 groups examined patients recovering from operative procedures (anterior cruciate ligament repair, knee arthroscopy, lateral retinacular release, total knee and hip arthroplasties, and carpal tunnel release). Additionally, the mode of cryotherapy varied widely, as did the duration and frequency of cryotherapy application. The time period when cryotherapy was applied after injury ranged from immediately after injury to 1 to 3 days postinjury. Adequate information on the actual surface temperature of the cooling device was not provided in the selected studies. Most authors recorded outcome variables over short periods (1 week), with the longest reporting follow-ups of pain, swelling, and range of motion recorded at 4 weeks postinjury. Data in that study were insufficient to calculate effect size. Nine studies did not provide data of the key outcome measures, so individual study effect estimates could not be calculated. A total of 12 treatment comparisons were made. Ice submersion with simultaneous exercises was significantly more effective than heat and contrast therapy plus simultaneous exercises at reducing swelling. Ice was reported to be no different from ice and low-frequency or high-frequency electric stimulation in effect on swelling, pain, and range of motion. Ice alone seemed to be more effective than applying no form of cryotherapy after minor knee surgery in terms of pain, but no differences were reported for range of motion and girth. Continuous cryotherapy was associated with a significantly greater decrease in pain and wrist circumference after surgery than intermittent cryotherapy. Evidence was marginal that a single simultaneous treatment with ice and compression is no more effective than no cryotherapy after an ankle sprain. The authors reported ice to be no more effective than rehabilitation only with regard to pain, swelling, and range of motion. Ice and compression seemed to be significantly more effective than ice alone in terms of decreasing pain. Additionally, ice, compression, and a placebo injection reduced pain more than a placebo injection alone. Lastly, in 8 studies, there seemed to be little difference in the effectiveness of ice and compression compared with compression alone. Only 2 of the 8 groups reported significant differences in favor of ice and compression.

FDA informed healthcare professionals and patients of the Agency’s investigation of the possible association between the use of Singulair and behavior/mood changes, suicidality (suicidal thinking and behavior) and suicide. Singulair is a leukotriene receptor antagonist used to treat asthma and the symptoms of allergic rhinitis, and to prevent exercise-induced asthma. Patients should not stop taking Singulair before talking to their doctor if they have questions about the new information. Healthcare professionals and caregivers should monitor patients taking Singulair for suicidality (suicidal thinking and behavior) and changes in behavior and mood.

This early communication is in keeping with FDA’s commitment to inform the public about its ongoing safety reviews of drugs. Due to the complexity of the analyses, FDA anticipates that it may take up to 9 months to complete the ongoing evaluations. As soon as this review is complete, FDA will communicate the conclusions and recommendations to the public.

From Pain Medicine Published article online: 11-Mar-2008

Objective. Chronic pain is a common reason for seeking medical care. We estimated the prevalence of chronic regional and widespread pain in the United States population overall, and by age, sex, and race/ethnicity.

Setting. We examined the data from 10,291 respondents who participated in the 1999–2002 NHANES (National Health and Nutrition Examination Survey) and completed a pain questionnaire. Items allowed classification of chronic (≥3 months) pain as regional or widespread. We used regression models to test the association of sex and race/ethnicity with each pain outcome, adjusting for age.

Results. Chronic pain prevalence estimates were 10.1% for back pain, 7.1% for pain in the legs/feet, 4.1% for pain in the arms/hands, and 3.5% for headache. Chronic regional and widespread pain were reported by 11.0% and 3.6% of respondents, respectively. Women had higher odds than men for headache, abdominal pain, and chronic widespread pain. Mexican-Americans had lower odds compared with non-Hispanic whites and blacks for chronic back pain, legs/feet pain, arms/hands pain, and regional and widespread pain.

Conclusion. The population prevalence of chronic pain in the United States was lower than previously reported, with smaller sex-related differences and some variation by race/ethnicity.