Monday, February 23, 2015

Low back pain affects 80% of the population at some point and can cause visits to the DC, MD, PT for costly assistance and, in some cases, require spinal surgical intervention. But can the things that trigger LBP be avoided if you knew what those triggers were? An Australian study indicates that many may indeed be modifiable.


  From  Medpage Today -

Low Back Pain Triggers: Many Are Modifiable

Triggers include both physical and psychosocial factors


  • by Wayne Kuznar
    Contributing Writer


Triggers for an episode of low back pain include both physical factors, such as manual tasks involving heavy loads and awkward posture, and psychosocial factors, such as fatigue, during performance of a task.

Odds ratios for these triggers ranged from 2.7 to 25.0, according to results from a case-crossover study, led by Daniel Steffens at the University of Sydney, Australia.

Writing in Arthritis Care and Research, the investigators state, "Our study adds to knowledge on risk of back pain by demonstrating for the first time that brief exposure to a range of modifiable physical and psychosocial factors increases the risk of an episode of back pain."

They employed a case-crossover design to quantify the risk associated with transient exposure to modifiable triggers for back pain. Exposure to triggers during the 2 hours before an episode of back pain (termed the "case window") was compared with exposure in the 24 and 48 hours before back pain onset ("control windows") in 999 subjects with a new episode of acute low back pain.

Physical triggers included manual tasks involving heavy loads or awkward positioning, handling live people or animals, physical activity, sexual activity, and slipping, tripping, or falling. Psychosocial triggers included alcohol consumption and being distracted or fatigued.

The mean duration of back pain episode was 4.9 days.

Exposure to all physical triggers occurred more often in the case window compared with the two control windows. In the case window, exposure to manual tasks involving an awkward posture was the most frequent physical trigger, 27.4%, compared with 7% for the first control window and 5.4% for second control window).

Manual tasks involving heavy loads was the second most common physical trigger during the case window, 17.9%, compared with 6.4% and 5.9% in the first and second control windows, respectively.
Among psychosocial triggers, fatigue was reported more often in the case window than in the two control windows (11.8% versus 6.90% and 6.00% in the first and second control windows, respectively).

Exposure frequency for being fatigued and tired was higher in the case window (11.8%) than control windows (6.90% and 6.00% in the first and second control windows, respectively). Exposure frequency was similar across case and control windows for sexual activity and alcohol consumption.
All physical triggers assessed were strongly associated with an increased risk of back pain. Odds ratios (ORs) for physical triggers of back pain onset were as follows:
  • Manual tasks involving awkward positioning, 8.0 (95% CI 5.5-11.8)
  • Manual tasks involving objects not close to the body, 6.2 (95% CI 2.4-16.0)
  • Manual tasks involving live people or animals, 5.80 (95% CI 2.3-15.0)
  • Manual tasks involving unstable or unbalanced objects, 5.1 (95% CI 2.4-10.9).
Exposure to physical activity of at least moderate intensity during the case window carried an OR of 2.7 (95% CI 2.0-3.6) compared with no exposure to physical activity, and exposure to physical activity of vigorous intensity increased it further to 3.9 (95% CI 2.4-6.3).

Psychosocial triggers that significantly increased the odds of new onset of back pain were distraction during a task or activity (OR 25.0; 95% CI 3.4-184.5), or fatigue (OR 3.7; 95% CI 2.2-6.3). Alcohol consumption and sexual activity showed no association with onset of back pain.

Thirty-seven subjects slipped, tripped or fell in the 2 hours before back pain onset, compared with one in the first control window and none in the second control window. "This suggests a strong association between this trigger and onset of back pain; however, exposure frequencies were very small in the control windows and slip, trip, or fall could not be sensibly included in the regression analyses," the authors wrote.

Older age moderated the effect of exposure to manual tasks involving heavy loads (P=0.01) but increased the risk with exposure to sexual activity (P=0.04). The authors state that this is the first study to find a decrease in risk with age with exposure to heavy loads.

Morning was the most frequent time of day for back pain onset. "The strong diurnal pattern for back pain onset would suggest that the morning may be a key time to intervene in order to prevent back pain," the authors wrote, noting that restriction of lumbar flexion in the morning reduced pain in one study of patients with persistent low back pain.

Recall bias is a potential limitation, wrote the investigators, but the recall period in this study was short (5 days). Also, the study did not control for time-variant confounders beyond the triggers included.

Tuesday, February 17, 2015

For patients considering injections into the knee to reduce the pain from arthritis and soft tissue damage, the choice comes down often to a corticosteroid or hyaluronic acid. Now a new study shows that while steroids act quicker, the hyaluronic acid has better long term benefits. Which would you choose if you needed the injection?

MedpageToday -

Rheumatology 1 Comment
 

Knee Injections in OA: Which Is Best?

Hyaluronic acid and steroids both improved symptoms, but there were differences.




Intra-articular injections of both hyaluronic acid and steroids were associated with symptom improvement in knee osteoarthritis (OA), but the pattern of response differed between the two treatments, a prospective, randomized study found.

At 3 months, patients who had injections of betamethasone had a 66.3% reduction in pain (95% CI 63.3-69.3) compared with a 48.5% reduction (95% CI 45.8-51.3) for those given hyaluronic acid injections (P<0.0001), according to Cesareo Angel Trueba Davalillo, MD, of the School of Medicine, Universidad Nacional Autonoma de Mexico in Mexico City, and colleagues.

However, by 12 months, the mean decrease in pain in the hyaluronic acid group was 33.6% (95% CI 31.1-36.1) compared with only 8.2% (95% CI 5.2-11.1) among those receiving betamethasone (P<0.0001), the researchers reported online in Open Access Rheumatology: Research and Reviews.

Injections of corticosteroids have been used for 6 decades in knee OA, and various treatment guidelines, including those of the American College of Rheumatology and the Osteoarthritis Research Society International, recommend them.

Injections of hyaluronic acid, first described more than 20 years ago, also are widely used today as a nonsurgical therapy for knee OA.

"Hyaluronic acid is a key molecule in joint biomechanics because of the fact that treatment with exogenous hyaluronic acid contributes to the restoration of the elastic and viscous properties of the synovial fluid, resulting in pain reduction and functional improvement," the researchers explained.
"Moreover, different studies have confirmed that hyaluronic acid interacts with inflammation mediators and matrix turnover in joint cells, reduces the apoptosis of chondrocytes, and exerts a biosynthetic-chondroprotective effect," they added.

Previous studies comparing the two have been hampered by small numbers and short duration and have had conflicting results, so Davalillo and colleagues enrolled 200 patients with grades II and III radiographic OA for a yearlong study.

The treatment consisted of five weekly intra-articular injections of hyaluronic acid (2.5 mL of 1% hyaluronic acid) or two injections one month apart of betamethasone dipropionate, 5 mg plus 2 mg in 1 mL betamethasone sodium phosphate.

Before each injection, arthrocentesis was done to clear any effusion. For the first month, all participants also received glucosamine (1,500 mg) plus meloxicam (15 mg) followed by a month of glucosamine (1,500 mg) plus chondroitin (1,200 mg).

The majority of patients were women and mean age was 63.

Body mass index was significantly higher in the hyaluronic acid group (28.3 versus 26.3 kg/m2, P=0.002) and more were obese (40.2% versus 24.5%).

At baseline, global pain scores were higher in the betamethasone group (6.6 versus 6.1, P=0.004), while functional status as rated on the Western Ontario McMaster University Osteoarthritis (WOMAC) was worse in the hyaluronic acid group (53.2 versus 48.4, P=0.001).

WOMAC function scores favored hyaluronic acid at months 3, 6, 9, and 12, with mean improvements of 47.5% (95% CI 45.6-49.3) at the end of follow-up compared with 13.2% (95% CI 11.4-14.9) in the betamethasone group (P<0.0001).

The percentage of patients achieving a minimal clinically important absolute improvement of 15 out of 100 points was almost 100% in both groups at 6 months. However, by 9 months the percentage in the hyaluronic acid group was 81.4% but only 9.2% in the betamethasone group (P<0.0001).

And the minimal clinically important relative improvement of 20% was seen in 87.6% of the hyaluronic acid group at 9 months compared with 10.2% of the betamethasone group (P<0.0001).
Similar numbers of patients (67%) in the two groups reported using acetaminophen as a rescue medication during the study.

The only adverse events reported were pain from the injection in four patients receiving hyaluronic acid and two given betamethasone, and one case of erythema in the hyaluronic acid group.

As to the changes in response over time, with more rapid pain relief being seen with betamethasone and better function throughout with hyaluronic acid, Davalillo and colleagues wrote, "It has been reported that corticosteroids have a short-term effect on pain but have no effect on function, whereas hyaluronic acid products can provide a more durable response with relief of pain and improvement in function, although the onset of these effects is slower."

A limitation of the study was baseline differences between the two groups, especially in body mass index and obesity.

The authors reported no conflicts of interest.
  • Reviewed by F. Perry Wilson, MD, MSCE Assistant Professor, Section of Nephrology, Yale School of Medicine and Dorothy Caputo, MA, BSN, RN, Nurse Planner

Wednesday, February 11, 2015

I'm in luck; the new equation for longer life is: Run Slow=Live Long. A new study published indicates that slower jogging improves mortality rates better than does quick running. But no matter which you prefer, movement and exercise remain beneficial.

New York Times Health - 

Slow Runners Come Out Ahead

 


The ideal amount of running for someone who wants to live a long and healthy life is less than most of us might expect, according to a new study, which also suggests that people can overdo strenuous exercise and potentially shorten their lives.

There is increasing consensus among physicians and exercise scientists that people should exercise intensely at least sometimes. Past studies have found, for instance, that walkers who move at a brisk pace tend to live longer than those who stroll, even if they cover about the same distance. 

Similarly, a 2012 study of cyclists in Denmark concluded that those who regularly rode hard tended to live longer than those who rode gently, even if the easy riders put in more hours on the road each week. 

But that result, while intriguing, felt unsatisfyingly vague to the Danish researchers. It did not delineate just how much intense exercise might be most protective against premature death. It also didn’t address whether there could be a ceiling to the benefits from vigorous exercise and, in terms of lifespan, whether someone might work out too much. 

So for the new study, which was published this month in The Journal of the American College of Cardiology, the researchers, most of them affiliated with the University of Copenhagen, turned to the enormous database about health habits among Danes known as the Copenhagen City Heart Study.
In this case, instead of focusing on cycling, the researchers decided to look at jogging, since it is the most popular strenuous activity worldwide. 

The researchers culled data for 1,098 adult men and women of varying ages who, upon their entry into the study in 2001, had identified themselves as joggers. They also had provided information about how often they ran per week, at what pace, and for how long. 

The researchers also pulled records for 3,950 age-matched volunteers who had said in 2001 that they did not engage in any type of vigorous exercise or, in fact, any exercise at all. 

All of the volunteers were generally healthy, however, without evidence at the time of disease or obesity. 

Then last year, the researchers compared the names of the volunteers in both groups against death records. They also determined whether, based on average life expectancies, the volunteers were living longer, or had shortened lifespans.

As it turned out, and as expected, joggers consistently tended to live longer than people who did not exercise. 

But when the researchers closely parsed the data about how much and how intensely people jogged, some surprises emerged. 

The ideal amount of jogging for prolonged life, this nuanced analysis showed, was between 1 hour and 2.4 hours each week. And the ideal pace was slow. (The researchers did not specify exact paces in their study, using instead the broad categories of slow, average and fast, based on the volunteers’ self-reported usual pace.) 

Plodding joggers tended to live longer than those who ran faster. In fact, the people who jogged most often and at the fastest pace — who were, in effect, runners rather than joggers — did not enjoy much benefit in terms of mortality. In fact, their lifespans tended to be about the same as those who did not exercise at all. 

The results suggest that the “optimal dose of jogging is light, and strenuous joggers and sedentary non-joggers have similar mortality rates,” said Jacob Louis Marott, a researcher for the Copenhagen City Heart Study and a co-author of the study.

You can, in other words, potentially run too much.

Of course, there are caveats. The number of hardcore runners in the study was quite small, for one thing, consisting of barely 80 men and women. So any statistical information about death rates among that group must be viewed cautiously, as the scientists acknowledge. 

And perhaps most important, the researchers did not determine how and why the runners and nonrunners had died. So it is impossible to draw any conclusions about what deleterious effects, if any, hard and prolonged exercise might have on our bodies. There could be scarring or other impacts on the heart muscle after years of strenuous exercise, the Danish scientists suggest, though that possibility remains completely speculative at the moment.

So the message of this study remains that sweaty exercise is generally healthy and desirable – but a little sweat goes a long ways. Even slow jogging counts as “vigorous exercise,” Mr. Marott said and, as this study showed, can lengthen lifespans.

Friday, February 6, 2015

A healthy business, healthy work environment, healthy employees...how does it happen? In leading a collaboration of leaders from over 50 stakeholder organizations focused on the economic and cultural development of a community, I think success will come if this collection of individuals can tap into their imagination. Imagination is an excellent foundation for business culture and a Harvard Business Review article provides a case for "Management by Imagination."

 
 

Management by Imagination


The perception that good management is closely linked to good measurement runs deep. How often do you hear these old saws repeated: “If you can’t measure it, it doesn’t count”; “If you can’t measure it, you can’t manage it”; “If you can’t measure it, it won’t happen”? We like these sayings because they’re comforting. The act of measurement provides security; if we know enough about something to measure it we almost certainly have some control over it.

But however comforting it can be to stick with what we can measure, we run the risk of expunging something really important. What’s more, we won’t see what we’re missing because we don’t know what it is that we don’t know. By sticking simply to what we can measure, we come to imagine a small and constrained world in which we are prisoners of a “reality” that is in fact an edifice we’ve unknowingly constructed around ourselves.

The late 19th and early 20th century American pragmatist philosopher Charles Sanders Peirce was the first to point out that no new idea in the world was ever produced by inductive or deductive logic. Analyzing the past, crunching the existing numbers to produce the future can do nothing more than extrapolate the future from the past. So if you stick to measuring what you can already measure, you cannot create a future that is different than the past.

For that to work out at all well for any institution making its decisions on that extrapolation, the future needs to be remarkably similar to the past — or bad things start to happen. If an institution is all geared up for a future that is like the past and the future changes radically, then the institution becomes an anachronism, like a Motorola or GM.

Managers in this situation tend to blame forces beyond their control: “How could we have ever predicted such a change?” In some sense, they are absolutely right. They had no way at all of predicting change. Their core conception — “If you can’t measure it, it doesn’t count” — precludes them from demonstrating to themselves that the future will be anything but an extrapolation of the past. Note however, that it is a prison that they have built for themselves. They build it, lock themselves in a cell, throw away the key; and then complain about being unfairly locked in a prison cell.

We need to get away from all those old sayings about measurement and management, and in that spirit I’d like to propose a new wisdom: “If you can’t imagine it, you will never create it.” The future is about imagination, not measurement. To imagine a future, one has to look beyond the measurable variables, beyond what can be proven with past data. While Motorola was projecting future sales volumes of “feature phones,” Mike Lazaridis, founder of Research in Motion, was imagining what executive life would be like if you could receive your emails on a handheld device. How compelling would an ordinary phone be if you could have a BlackBerry attached to your belt? He couldn’t “prove” that this would be a good idea. There was no data on the demand patterns for smartphones, because smartphones existed only in his imagination. But a mere 11 years after the launch of the product of his imagination, RIM leads Motorola by an ever-accelerating margin in sales, market share and profitability.

Long ago, Peirce coined a term for the thinking that Lazaridis used to create the BlackBerry: abductive logic. He referred to it as “inference to the best explanation” and “a logical leap of the mind.” Lazaridis couldn’t prove that executives would become so addicted to his invention that it would acquire the nickname CrackBerry. But as he watched executives behave in their day-to-day work, he inferred that there was a good chance that they would highly value immediate access to their email regardless of whether they were at their desk or on the road. There was nothing to measure. What counted were inferences; inferences made on lots of qualitative insights and “a logical leap of the mind.”

The difference in the world of a Mike Lazaridis vs. the “if you can’t measure it…” executives is like day and night. For the abduction logician, the world is expansive and the possibilities are endless. For the measurement types, the world is a brutal place, full of nasty surprises that are impossible to predict. That is why any expression that starts with “if you can’t measure it” is dangerous for your managerial health.

Roger Martin is the Dean of the Rotman School of Management at the University of Toronto in Canada and the author of The Design of Business: Why Design Thinking is the Next Competitive Advantage (Harvard Business Press, 2009).

Sunday, February 1, 2015

Monitoring your fitness with a tracker, recording your food consumption, and weighing in daily work because it helps keep a focus your diet. Now a new study that "friending" someone also on a journey to weight loss is an effective tool to becoming more healthy. That you "do" rather than just "talk" about your goals remains important to your wellbeing.


MNT - Hourly Medical News Since 2003

'Friending' your way thin

Last updated:


Dieters who make more connections in online weight-loss communities lose more weight 

If you want to lose pounds using an online weight management program, don't be a wallflower. A new Northwestern University study shows that online dieters with high social embeddedness -- who logged in regularly, recorded their weigh-ins and 'friended' other members -- lost more than 8 percent of their body weight in six months.

The less users interacted in the community, the less weight they lost, the study found.
"Our findings suggest that people can do very well at losing weight with minimal professional help when they become centrally connected to others on the same weight loss journey," said Bonnie Spring, an author of the study and professor in preventive medicine at Northwestern University Feinberg School of Medicine.

The study, published in the Journal of the Royal Society Interface, is the first to use data from an online weight management program to investigate social network variables and reveal which aspects of online social connectedness most strongly promote weight loss.

The scientists found that users who did not connect with others lost about 5 percent of their body weight over six months, those with a few friends (two to nine) lost almost 7 percent and those with more than ten friends lost more than 8 percent.

"There is an almost Facebook-like social network system in this program where people can friend each other and build cliques," said Luís A. Nunes Amaral, senior author of the study. "In this case, we found the larger your clique, the better your outcomes."

Amaral is a professor of chemical and biological engineering in the McCormick School of Engineering and Applied Science and a leading researcher in the areas of big data and complex systems. His also is co-director of the Northwestern Institute on Complex Systems (NICO).

Spring, who also is the director at the Center for Behavior and Health in the Institute for Public Health and Medicine at Feinberg, and Amaral met through a common interest in the science of teamwork and collaborated on this research.

Spring had access to a large dataset from CalorieKing.com's online weight-loss community. Users of CalorieKing's program pay a membership fee for access to weight-loss tools and an online community. Amaral's lab had the expertise to analyze user data and uncover trends in this complex network.

The data provided did not include the identities of users, but it provided their sign-up date, age, height, gender and initial weight and time-stamped activities within the online community for nearly a year. Engagement, such as recorded weigh-ins, friendship requests and online communication, was analyzed. The scientists didn't have access to any of the text that was exchanged between users.

"We found that the frequency with which you report your weight is a good indictor of positive outcomes," Amaral said. "If you monitor your weight, you are engaged.f you communicate online with other people you are even more engaged, and when you need support you might be able to get it. There are some nice characteristics about this social network."

The gold standard for weight loss is intensive lifestyle treatment involving a minimum of 16 60-to-90 minute individual or group treatment sessions covering diet, physical activity,and behavior change, Spring said. Those who regularly track their progress, known as self-monitoring, lose more weight in clinical studies.

This study found that self-monitoring was associated with greater weight loss, too, but Spring was surprised that even greater weight loss was associated with being highly embedded in a network of other people trying to lose weight.

"In the clinic, we don't have the ability to connect people with such a large network of others on the same journey to lose weight," Spring said. "I was very surprised by how lawfully each step-up in social connectedness translated into greater weight loss. We could clearly see the benefit of the online social network for weight-loss success."

For those lacking time or geographic proximity to attend in-person weight loss treatment, an online weight loss program seems to be a good alternative, Spring said, particularly if you take advantage of the self-monitoring and social networking features.

Amaral said this online social support community approach could work in other areas of behavioral medicine -- such as depression and alcoholism -- where in-person meetings are recommended.

"Modern life is so complex and stressful, to go somewhere for a meeting is often not practical," Amaral said. "It is hopeful that this alternative approach, of going online for support, could work."