Chronic non-specific low back pain - sub-groups or a single mechanism?

Copyright 2008 Wand and O'Connell; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Background: Low back pain is a substantial health problem and has subsequently attracted a considerable amount of research. Clinical trials evaluating the efficacy of a variety of interventions for chronic non-specific low back pain indicate limited effectiveness for most commonly applied interventions and approaches. Discussion: Many clinicians challenge the results of clinical trials as they feel that this lack of effectiveness is at odds with their clinical experience of managing patients with back pain. A common explanation for this discrepancy is the perceived heterogeneity of patients with chronic non-specific low back pain. It is felt that the effects of treatment may be diluted by the application of a single intervention to a complex, heterogeneous group with diverse treatment needs. This argument presupposes that current treatment is effective when applied to the correct patient. An alternative perspective is that the clinical trials are correct and current treatments have limited efficacy. Preoccupation with sub-grouping may stifle engagement with this view and it is important that the sub-grouping paradigm is closely examined. This paper argues that there are numerous problems with the sub-grouping approach and that it may not be an important reason for the disappointing results of clinical trials. We propose instead that current treatment may be ineffective because it has been misdirected. Recent evidence that demonstrates changes within the brain in chronic low back pain sufferers raises the possibility that persistent back pain may be a problem of cortical reorganisation and degeneration. This perspective offers interesting insights into the chronic low back pain experience and suggests alternative models of intervention. Summary: The disappointing results of clinical research are commonly explained by the failure of researchers to adequately attend to sub-grouping of the chronic non-specific low back pain population. Alternatively, current approaches may be ineffective and clinicians and researchers may need to radically rethink the nature of the problem and how it should best be managed

Resource allocation of in vitro fertilization: a nationwide register-based cohort study

<p>Abstract</p> <p>Background</p> <p>Infertility is common and in vitro fertilization (IVF) is a widely used treatment. In IVF the need increases and the effectiveness and appropriateness decrease by age. The purpose of this study was to describe allocation of resources for IVF by women's age, socioeconomic position, area of residence and treatment sector (public vs. private) and to discuss how fairly the IVF resources are allocated in Finland.</p> <p>Methods</p> <p>Women who received IVF between 1996 and 1998 (N = 9175) were identified from the reimbursement records of the Social Insurance Institution (SII). Information on IVF women's background characteristics came from the Central Population Register and the SII, on treatment costs from IVF clinics and the SII, and on births from the Medical Birth Register. The main outcome measures were success of IVF by number of cycles and treated women, expenditures per IVF cycles, per women, per live-birth, and per treatment sector, and private and public expenditures. Expenditures were estimated from health care visits and costs.</p> <p>Results</p> <p>During a mean period of 1.5 years, older women (women aged 40 or older) received 1.4 times more IVF treatment cycles than younger women (women aged below 30). The success rate decreased by age: from 22 live births per 100 cycles among younger women to 6 per 100 among older women. The mean cost of a live birth increased by age: compared to younger women, costs per born live birth of older women were 3-fold. Calculated by population, public expenditure was allocated most to young women and women from the highest socioeconomic position. Regional differences were not remarkable.</p> <p>Conclusion</p> <p>Children of older infertile women involve more expense due to the lower success rates of IVF. Socioeconomic differences suggest unfair resource allocation in Finland.</p

Anxiety and depression among infertile women: a cross-sectional survey from Hungary

BACKGROUND: Infertility is often associated with a chronic state of stress which may manifest itself in anxiety-related and depressive symptoms. The aim of our study is to assess the psychological state of women with and without fertility problems, and to investigate the background factors of anxiety-related and depressive symptoms in women struggling with infertility. METHODS: Our study was conducted with the participation of 225 (134 primary infertile and 91 fertile) women, recruited in a clinical setting and online. We used the following questionnaires: Spielberger Trait Anxiety Inventory (STAI-T), Shortened Beck Depression Inventory (BDI) and Fertility Problem Inventory (FPI). We also interviewed our subjects on the presence of other sources of stress (the quality of the relationship with their mother, financial and illness-related stress), and we described sociodemographic and fertility-specific characteristics. We tested our hypotheses using independent-samples t-tests (M +/- SD) and multiple linear regression modelling (ss). RESULTS: Infertile women were younger (33.30 +/- 4.85 vs. 35.74 +/- 5.73, p = .001), but had significantly worse psychological well-being (BDI = 14.94 +/- 12.90 vs. 8.95 +/- 10.49, p < .0001; STAI-T = 48.76 +/- 10.96 vs. 41.18 +/- 11.26, p < .0001) than fertile subjects. Depressive symptoms and anxiety in infertile women were associated with age, social concern, sexual concern and maternal relationship stress. Trait anxiety was also associated with financial stress. Our model was able to account for 58% of the variance of depressive symptoms and 62% of the variance of trait anxiety. CONCLUSIONS: Depressive and anxiety-related symptoms of infertile women are more prominent than those of fertile females. The measurement of these indicators and the mitigation of underlying distress by adequate psychosocial interventions should be encouraged

Influence of Psychological Factors on Pain and Disability in Anterior Knee Pain Patients

AKP patients express chronic pain but also disability. However, the correlation between pain and disability is not complete and linear. Some patients with a lot of pain show mild disability while others with much less pain also show great disability. The disability is profoundly influenced by other emotional and cognitive factors that are associated with the perception of pain. Therefore, the clinical efforts do not have to be focused only on treating the pain as a feeling but on identifying and modifying these factor

Occipital peripheral nerve stimulation in the management of chronic intractable occipital neuralgia in a patient with neurofibromatosis type 1: a case report

<p>Abstract</p> <p>Introduction</p> <p>Occipital peripheral nerve stimulation is an interventional pain management therapy that provides beneficial results in the treatment of refractory chronic occipital neuralgia. Herein we present a first-of-its-kind case study of a patient with neurofibromatosis type 1 and bilateral occipital neuralgia treated with occipital peripheral nerve stimulation.</p> <p>Case presentation</p> <p>A 42-year-old Caucasian woman presented with bilateral occipital neuralgia refractory to various conventional treatments, and she was referred for possible treatment with occipital peripheral nerve stimulation. She was found to be a suitable candidate for the procedure, and she underwent implantation of two octapolar stimulating leads and a rechargeable, programmable, implantable generator. The intensity, severity, and frequency of her symptoms resolved by more than 80%, but an infection developed at the implantation site two months after the procedure that required explantation and reimplantation of new stimulating leads three months later. To date she continues to experience symptom resolution of more than 60%.</p> <p>Conclusion</p> <p>These results demonstrate the significance of peripheral nerve stimulation in the management of refractory occipital neuralgias in patients with neurofibromatosis type 1 and the possible role of neurofibromata in the development of occipital neuralgia in these patients.</p

Psychological correlates of self-reported functional limitation in patients with ankylosing spondylitis

Abstract Introduction Functional status is an integral component of health-related quality of life in patients with ankylosing spondylitis (AS). The purpose of this study was to investigate the role of psychological variables in self-reported functional limitation in patients with AS, while controlling for demographic and medical variables. Methods 294 AS patients meeting modified New York Criteria completed psychological measures evaluating depression, resilience, active and passive coping, internality and helplessness at the baseline visit. Demographic, clinical, and radiologic data were also collected. Univariate and multivariate analyses were completed to determine the strength of correlation of psychological variables with functional limitation, as measured by the Bath AS Functional Index (BASFI). Results In the multivariate regression analysis, the psychological variables contributed significantly to the variance in BASFI scores, adding an additional 24% to the overall R-square beyond that accounted by demographic and medical variables (R-square 32%), resulting in a final R-square of 56%. Specifically, arthritis helplessness, depression and passive coping beside age, ESR and the Bath AS Radiograph Index accounted for a significant portion of the variance in BASFI scores in the final model. Conclusions Arthritis helplessness, depression, and passive coping accounted for significant variability in self-reported functional limitation beyond demographic and clinical variables in patients with AS. Psychological health should be examined and accounted for when assessing functional status in the AS patients

Individual and contextual covariates of burnout: a cross-sectional nationwide study of French teachers

<p>Abstract</p> <p>Background</p> <p>Limited information on the covariates of burnout syndrome in French teachers is available. The aim of this study was to evaluate the relative contributions of individual and contextual factors on the three burnout dimensions: emotional exhaustion, depersonalization, and reduced personal accomplishment.</p> <p>Methods</p> <p>The source data come from an epidemiological postal survey on physical and mental health conducted in 2005 among 20,099 education workers (in activity or retired) selected at random from the health plan records of the national education system. The response rate was 52.4%. Teachers in activity currently giving classes to students who participated in the survey (n = 3,940) were invited to complete a self-administered questionnaire including the Maslach Burnout Inventory. 2,558 teachers provided complete data (64.9%). Variables associated with high emotional exhaustion (highest quartile of score), high depersonalization (highest quartile), and reduced personal accomplishment (lowest quartile) were evaluated using multivariate logistic regression. Studied variables referred to demographic characteristics, socio-professional environment, job dissatisfaction, experienced difficulties at work, and teaching motivations.</p> <p>Results</p> <p>Different variables were associated with each burnout dimension. Female teachers were more susceptible to high emotional exhaustion and reduced personal accomplishment, whereas male teachers were more susceptible to high depersonalization. Elementary school teachers were more susceptible to high emotional exhaustion, but less susceptible to high depersonalization and reduced personal accomplishment than their higher school level counterparts. Experienced difficulties with pupils were associated with all three dimensions. A socio-economically underprivileged school neighbourhood was also related to high emotional exhaustion and high depersonalization.</p> <p>Conclusion</p> <p>Programs to enhance teaching environment might be an interesting approach to try to prevent burnout. It would be useful to take the different dimensions into account in planning the intervention.</p

Testing the effectiveness of a mindfulness-based intervention to reduce emotional distress in outpatients with diabetes (DiaMind): design of a randomized controlled trial

<p>Abstract</p> <p>Background</p> <p>Approximately 20-40% of outpatients with diabetes experience elevated levels of emotional distress, varying from disease-specific distress to general symptoms of anxiety and depression. The patient's emotional well-being is related to other unfavorable outcomes, like reduced quality of life, sub-optimal self-care, impaired glycemic control, higher risk of complications, and increased mortality rates. The purpose of this study is to test the effectiveness of a new diabetes-specific, mindfulness-based psychological intervention. First, with regard to reducing emotional distress; second, with respect to improving quality of life, dispositional mindfulness, and self-esteem of patients with diabetes; third, with regard to self-care and clinical outcomes; finally, a potential effect modification by clinical and personality characteristics will be explored.</p> <p>Methods/Design</p> <p>The Diabetes and Mindfulness study (DiaMind) is a randomized controlled trial. Patients with diabetes with low levels of emotional well-being will be recruited from outpatient diabetes clinics. Eligible patients will be randomized to an intervention group or a wait-list control group. The intervention group will receive the mindfulness program immediately, while the control group will receive the program eight months later. The primary outcome is emotional distress (anxiety, stress, depressive symptoms), for which data will be collected at baseline, four weeks, post intervention, and after six months follow-up. In addition, self-report data will be collected on quality of life, dispositional mindfulness, self-esteem, self-care, and personality, while complications and glycemic control will be assessed from medical files and blood pressure will be measured. Group differences will be analyzed with repeated measures analysis of covariance.</p> <p>The study is supported by grants from the Dutch Diabetes Research Foundation and Tilburg University and has been approved by a medical ethics committee.</p> <p>Discussion</p> <p>It is hypothesized that emotional well-being, quality of life, dispositional mindfulness, self-esteem, self-care, and blood pressure will improve significantly more in the mindfulness group compared to the control group. Results of this study can contribute to a better care for patients with diabetes with lowered levels of emotional well-being. It is expected that the first results will become available in 2012.</p> <p>Trial registration</p> <p>Dutch Trial Register <a href="http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=2145">NTR2145</a>.</p