Conservative treatment of patellar tendinopathy

Patellar tendinopathy disrupts athletic careers in several sports and is resistant to many forms of conservative treatment. Outcome after conservative treatment has been minimally investigated, and the effect of these treatments on the pathology of overuse tendinopathy are not well understood.

The clinical assessment of patellar tendinopathy appears straightforward, but evidence suggests that the importance of imaging and palpation in diagnosis and ongoing assessment may be overestimated. There is a lack of clinically relevant research on which to base treatment. However, the principles of management for patellar tendinopathy derived from clinical experience include load modification, musculotendinous rehabilitation, and intervention to improve the shock absorbing capacity of the limb. The role of electrophysical agents, massage, and stretching in the treatment of patellar tendinopathy are also discussed. The progression of treatment is based on clinical grounds due to a lack of reliable subjective and objective tools to assess recovery.

The failure of some conservative programs could be due to either athlete compliance or practitioner expertise. The management of patellar tendinopathy is complex, and if the physiotherapist addresses all the principles of treatment, the chance of success could be increased.

Guideline-based programs in the treatment of complex PTSD

The term “post-traumatic stress disorder” (PTSD) is a relatively new diagnostic label, being formally recognized in 1980 in the Diagnostic Statistical Manual for Psychiatric Illness – Third Edition (DSM-III) of the American Psychiatric Association (APA, 1980). Complex Post-Traumatic Stress Disorder (CP) is a more recently discussed, and newly-classified, phenomenon, initially discussed in the early 1990s (Herman, 1992a). Thus, as research into effective treatments for CP is sparse, the treatment of CP is the topic of this study, in which a guideline-based treatment program developed by the researcher for the treatment of CP is implemented and evaluated. Ten individuals participated in this study, undertaking individualized, guideline-based treatment programs spanning a period of six months. In providing background information relevant to this study, an explanation is provided regarding the nature of CP, and the reasons for its consideration as a separate phenomenon to PTSD. The adequacy of the PTSD formulation in enabling effective assessment and treatment of CP is also explored, with endorsement of previous researchers’ conclusions that the CP construct is more useful than the PTSD construct for assessing and treating survivors of long-term and multiple forms of abuse. The PTSD classification is restrictive, and not necessarily appropriate for certain forms of trauma (such as prolonged trauma, or multiple forms of trauma), as such trauma experiences may lead to specific effects that lay outside those formerly associated with PTSD. Such effects include alterations in affect regulation, consciousness, self-perception, interpersonal relationships, and in systems of meaning. Following discussion regarding the PTSD/CP classification, an examination of treatment methods currently used in the treatment of PTSD, and a review of treatment outcome studies, takes place. The adequacy of primary treatment methods in treating CP symptoms is then examined, with the conclusion that a range of treatment methods could potentially be useful in the treatment of CP symptoms. Individuals with a diagnosis of CP may benefit from the adoption of an eclectic approach, drawing on different treatment options for different symptoms, and constantly evaluating client progress and re-evaluating interventions. This review of treatment approaches is followed by details of an initial study undertaken to obtain feedback from individuals who had suffered long-term/multiple trauma and who had received treatment. Participants in this initial study were asked open-ended questions regarding the treatment approach they had experienced, the most useful aspect of the treatment, the least useful aspect, and other strategies/treatment approaches that may have been useful – but which were not used. The feedback obtained from these individuals was used to inform the development of treatment guidelines for use in the main study, as were recommendations made by Chu (1998). The predominant focus of the treatment guidelines was “ego strengthening”, a term coined by Chu (1998) to describe the “initial (sometimes lengthy) period of developing fundamental skills in maintaining supportive relationships, developing self-care strategies, coping with symptomatology, improving functioning, and establishing a positive self identity” (p.75). Using a case study approach, data are then presented relating to each of the ten individuals involved in the treatment program: details of his/her trauma experience(s)and the impact of the trauma (as perceived by each individual); details of each individual’s treatment program (as planned, and as implemented); post-treatment evaluation of the positive and negative aspects of the treatment program (from the therapist’s perspective); and details of the symptoms reported by the individual post-treatment, via psychometric assessment and also during interview. Analysis and discussion of the data relating to the ten participants in the study are the focal point of this study. The evaluation of the effectiveness of each individual’s treatment has been based predominantly on qualitative data, obtained from an analysis of language (discourse analysis) used by participants to describe their symptoms pre- and post-treatment. Both blatant and subtle changes in the language used by participants to describe themselves, their behaviour, and their relationships pre- and post-treatment have provided an insight into the possible changes that occurred as a result of the treatment program. The language used by participants has been a rich source of data, one that has enabled the researcher to obtain information that could not be obtained using psychometric assessment methods. Most of the participants in this study portrayed notable changes in many of the CP symptoms, including being more stable and having improved capacity to explore their early abuse. Although no direct cause-effect relationship between the participants’ treatment program and the improvements described can be established from this study, the participants’ perception that the program assisted them with their symptoms, and reported many aspects of “ego strengthening”, is of major importance. Such self-perception of strength and empowerment is important if an individual is going to be able to deal with past trauma experiences. In fact, abreactive work may have a greater chance of succeeding if those who have experienced long-term or multiple trauma are feeling more empowered, and more stable, as were the participants in this study (post-intervention). In concluding this study, recommendations have been made in regard to the use of guideline-based treatment programs in the responsible treatment of CP. Strengths and limitations of this study have also been highlighted, and recommendations have been made regarding possibilities for future research related to CP treatment. On the whole, this study has supported strongly other research that highlights the importance of focusing on “ego strengthening” in assisting those who have suffered long-term/multiple trauma experiences. Thus, a guideline-based program focusing on assisting sufferers of long-term trauma with some, or all, of the symptoms of CP, is recommended as an important first stage of any treatment of individuals who have experienced long-term/multiple trauma, allowing them to develop the emotional and psychological strength required to deal with past traumatic events. Clinicians who are treating patients whose history depicts long-term or multiple trauma experiences (either from their childhood, or at some stage in their adult life) need, therefore, to be mindful of assessing individuals for symptoms of CP – so that they can treat these symptoms prior to engaging in any work associated directly with the past traumatic experiences.

Motivation and coercion among mandated and voluntary drug treatment clients

Voluntary and mandated drug treatment clients were interviewed to investigate the role that motivation and perceived coercion had on their outcomes. The major findings were first, there were few differences between these two groups, and second, motivation was an important predictor of treatment outcome.

Rape : psychopathology, theory and treatment

Whether treatment programs are effective at rehabilitating rapists is yet to be determined empirically. From a scientist–practitioner perspective, treatment should be based on an empirical understanding of rape and rapists, and evidence-based knowledge of treatment outcome with rapists. In this paper we comprehensively review the characteristics of rapists, etiological features implicated in the commission of rape, and relevant treatment outcome research. We pay particular attention to contemporary knowledge about the core vulnerabilities and features required to understand and treat rapists effectively, and, where possible, highlight similarities and differences between rapists, child molesters and non-sexual violent offenders. We use an epistemological framework to (a) critique the various etiological accounts of rape available and (b) help guide professionals' use of such knowledge in both treatment design and evaluation. Gaps in the understanding of rapists' characteristics and etiological features are highlighted, as are discrepancies between current knowledge and treatment approaches. We conclude by highlighting areas for future research and practice innovation.

Self-monitoring in the treatment of overweight adolescents

The aim of this study was to explore the relationship between the quantity and quality of self-monitoring and per cent fat loss in overweight and obese adolescents participating in a weight-loss intervention. Participants were 55 (33F) overweight and obese adolescents taking part in a 20-week cognitive–behavioural intervention aimed at improving eating and physical activity behaviours. Food and physical activity self-monitoring from the first 9 weeks of the intervention was coded using 24 components assessing the quantity (20) and quality (4) of selfmonitoring. Those who completed treatment (n = 42) were split into groups: Losers (n = 30) and Gainers (n = 12) of per cent body fat as measured by DXA. Group analyses showed that Losers and Gainers could be differentiated by both quantitative and qualitative measures of self-monitoring. The strongest associations were with the classifications of food and drink items into food groups. The number of days monitored and the average number of items recorded did not differentiate the groups. Quantity and quality measures of self-monitoring completed early in treatment could also differentiate those who completed treatment and those who did not complete treatment (n = 13), and the strongest associations were with the amounts of food and drink items recorded, an association not found with treatment outcome. The results indicate that both quantity and quality of self-monitoring may be important predictors of both treatment completion and outcome. Based on these findings a framework of self-monitoring requirements is offered to reduce homework burden while maximising treatment efficacy.

Modifying the risk associated with an impulsive temperament: a prospective study of drug dependence treatment

The evidence linking the personality trait of impulsivity and substance misuse is well established. Importantly, impulsivity not only predicts substance misuse problems but has an association with duration in treatment, likelihood of completing treatment and time to relapse. Treatment that focuses on increasing awareness and acceptance of thoughts and emotions may potentially address impulsive behaviour and in this respect improve treatment outcomes for substance misuse. The current paper investigated the relationship between the facet of impulsivity that taps into poor inhibitory control and treatment outcome. In addition, there was a specific focus on ascertaining the impact of an increase in awareness and attentional control measured in 144 adult substance users receiving treatment in a residential therapeutic community. Impulsivity predicted poorer treatment outcome (measured as drug use severity). Increases in awareness and acceptance of emotions and thoughts during treatment were related to better outcome although this was not associated with baseline levels of impulsivity. Clinical and theoretical implications are discussed.

Efficacy of surgical versus conservative treatment in esophageal perforation: a systematic review of case series studies

PURPOSE: To evaluate the efficacy of surgical treatment for esophageal perforation. METHODS: A systematic review of the literature was performed. We conducted a search strategy in the main electronic databases such as PubMed, Embase and Lilacs to identify all case series. RESULTS: Thirty three case series met the inclusion criteria with a total of 1417 participants. The predominant etiology was iatrogenic (54.2%) followed by spontaneous cause (20.4%) and in 66.1% the localization was thoracic. In 65.4% and 33.4% surgical and conservative therapy, respectively, was considered the first choice. There was a statistically significance different with regards mortality rate favoring the surgical group (16.3%) versus conservative treatment (21.2%) (p<0.05). CONCLUSION: Surgical treatment was more effective and safe than conservative treatment concerning mortality rates, although the possibility of bias due to clinical and methodological heterogeneity among the included studies and the level of evidence that cannot be ruled out.

Alcoholic women and men: a comparative study of social and familial aspects and outcome

Objetivos: A proporção de ocorrência de alcoolismo em homens e mulheres tem uma variação de 14:1 até 2:1, mostrando a necessidade de estudos específicos para a população feminina. O objetivo deste estudo foi analisar o perfil e a evolução de alcoolistas, segundo gênero e gravidade da dependência. Métodos: Realizou-se um estudo longitudinal retrospectivo de 114 homens e 57 mulheres alcoolistas (CID-10), inscritos no ambulatório da Faculdade de Medicina de Botucatu, no período de 1990-1994 e avaliados até julho de 1997. Utilizou-se um questionário semi-estruturado, e, para avaliação da gravidade do alcoolismo, o Short Alcohol Dependence Data. Resultados/Conclusões: Os principais resultados mostraram que a estrutura familiar estava comprometida com: relacionamento difícil para 55,6% das mulheres e 65,7% dos homens; violência familiar em 74,1% das mulheres e 61,1% dos homens. As mulheres iniciaram a ingestão mais tarde que os homens (p=0,01), em geral com seus cônjuges (p=0,00). Não houve diferença de evolução no tratamento entre os gêneros. Os principais fatores associados à melhor resposta ao tratamento, independentemente do sexo, foram: nível de gravidade de dependência do álcool (dependentes leves e moderados apresentaram 5,59 vezes mais chances de melhorar do que os dependentes graves); ser praticante de alguma religião (2,3 vezes mais chances de melhora do que os pacientes que não eram praticantes); e tempo de seguimento no programa, negativamente correlacionado a chances de melhora (0,68 vezes menos chances de melhora que aqueles que permaneceram por tempo menor em tratamento).

Lethal photosensitization and guided bone regeneration in treatment of peri-implantitis: an experimental study in dogs

The purpose of this study was to evaluate the effect of lethal photosensitization and guided bone regeneration (GBR) on the treatment of ligature-induced peri-implantitis in different implant surfaces. The treatment outcome was evaluated by clinical and histometric methods. A total of 40 dental implants with four different surface coatings (10 commercially pure titanium surface (cpTi); 10 titanium plasma-sprayed (TPS); 10 acid-etched surface; 10 surface-oxide sandblasted) were inserted into five mongrel dogs. After 3 months, the animals with ligature-induced peri-implantitis were subjected to surgical treatment using a split-mouth design. The controls were treated by debridment and GBR, while the test side received an additional therapy with photosensitization, using a GaAlAs diode laser, with a wavelength of 830 nm and a power output of 50 mW for 80 s (4 J/cm(2)), and sensitized toluidine blue O (100 mu g/ml). The animals were sacrificed 5 months after therapy. The control sites presented an earlier exposition of the membranes on all coating surfaces, while the test group presented a higher bone height gain. Re-osseointegration ranged between 41.9% for the cpTi surface and 31.19% for the TPS surface in the test sites; however differences were not achieved between the surfaces. The lethal photosensitization associated with GBR allowed for better re-osseointegration at the area adjacent to the peri-implant defect regardless of the implant surface.

Treatment of gingival recession: Comparative study between subepithelial connective tissue graft and guided tissue regeneration

Background: Various procedures have been proposed to treat gingival recession, but few studies compare these procedures to each other. The purpose of this study was to evaluate a clinical comparison of subepithelial connective tissue graft (SCTG) and guided tissue regeneration (GTR) with a collagen membrane in the treatment of gingival recessions in humans. Methods: Twenty-four defects were treated in 12 patients who presented canine or pre-molar Miller Class I and/or II bilateral gingival recessions. Both treatments were performed in all patients, and clinical measurements were obtained at baseline and 18 months after surgery. These clinical measurements included gingival recession height (GR), root coverage (RC), probing depth (PD), keratinized tissue width (KT), and final esthetic result. Results: Both SCTG and GTR with a bioabsorbable membrane and bone graft demonstrated significant clinical and esthetic improvement for gingival recession coverage. The SCTG group was statistically significantly better than GTR for height of GR (SCTG = 0.2 mm, GTR = 1.12 mm, P = 0.02) and KT (SCTG = 4.58 mm, GTR = 2.5 mm, P <0.0001). However, PD was statistically significantly better for GTR than SCTG treatment (GTR = 1.66 mm, SCTG = 1.00, P = 0.01). The 2 procedures were statistically similar in root coverage (SCTG = 95.6%, GTR = 84.2%, P = 0.073). The esthetic condition after both treatments was satisfactory (P = 0.024). Conclusions: It was concluded that the gingival recessions treated with the SCTG group were superior for GR, RC, and KT clinical parameters, while GTR demonstrated better PD reduction. The final esthetic results were similar using both techniques.

Subgingival utilization of a 1% chlorhexidine collagen gel for the treatment of periodontal pockets. A clinical and microbiological study.

This study evaluates the effect of subgingival irrigation with a 1% chlorhexidine collagen gel in periodontal pockets as an adjunct procedure to scaling and root planing (SRP). Thirty-seven sites with probing depth (PD) of 5-7 mm and BANA positive in 6 patients with chronic periodontal disease were selected. Sites were assigned to different treatment groups consisting of SRP only (group 1), SRP + irrigation with collagen gel (group 2), or SRP + irrigation with collagen gel containing 1% chlorhexidine (group 3). Subgingival irrigation was performed after initial SRP and at 7, 14 and 21 days. Clinical measurements including PD, plaque index (PI), gingival index (GI), gingival recession (GI), bleeding on probing (BOP) and clinical attachment level (CAL) were performed at the selected sites at baseline, 60 and 90 days and the BANA test was performed on plaque samples from the same sites at baseline and 90 days. There was an improvement in clinical parameters in all groups with a significantly greater decrease in GI and bleeding in the chlorhexidine group. There was a greater reduction of BANA positive sites in groups 2 and 3. The authors concluded that 1% chlorhexidine collagen gel is a promising adjunct to SRP in the treatment of adult periodontitis.

Gelatinous polyethylene in the treatment of the anophthalmic cavity

PURPOSE: Gelatinous polyethylene (GP) has been used as an orbital implant to evaluate volume maintenance and tissue reaction in the anophthalmic socket in a rabbit model. METHODS: Twenty-eight Norfolk white rabbits underwent unilateral evisceration with placement of 2ml GP (GP group - 16 animals) or 2ml 0.9% sodium chloride solution (Control group - 12 animals). Animal behavior, postoperative tissue response and socket conditions were evaluated. The animals were sacrificed at 7, 15, 30 and 60 days after the surgery and the bulbs were enucleated; volume maintenance and histopathological evaluation were done in the enucleated bulbs. The results were submitted to statistical analysis. RESULTS: All animals showed normal behavior. The orbital volume maintenance was better in the GP group. Histopathology in the GP animals showed mild tissue inflammation throughout the evaluation period and a thin pseudocapsule formation surrounding the orbital implant material. CONCLUSION: The clinical findings, good orbital volume maintenance and mild inflammatory tissue response make GP a good choice to replace the lack of volume in anophthalmic socket reconstruction.

Treatment Effects Produced by Fränkel Appliance in Patients with Class II, Division 1 Malocclusion

The purpose of this investigation was to evaluate the dentoalveolar and skeletal cephalometric changes produced by the Fränkel appliance in individuals with a Class II, division 1 malocclusion. Lateral cephalograms of 44 patients of both sexes were divided in two groups of 22 each. The control group was comprised of untreated Class II children with an initial mean age of eight years and seven months who were followed without treatment for a period of 13 months. The Fränkel group had an initial mean age of nine years and was treated for a mean period of 17 months. Lateral cephalometric headfilms of each patient were obtained at the beginning and end of treatment. The Fränkel appliance produced no significant changes in maxillary growth during the evaluation period, while a statistically significant increase in mandibular length was observed. The maxillomandibular relationship improved mostly because of an increase in mandibular length. In addition, there were no statistically significant differences in the craniofacial growth direction between the Fränkel and the control group, both showing a slight downward rotation of the palatal plane. The Fränkel appliance produced a labial tipping of the lower incisors and a lingual inclination of the upper incisors as well as a significant increase in mandibular posterior dentoalveolar height. It was concluded that the main effects of the Fränkel appliance during this time period were mostly dentoalveolar with a smaller but significant skeletal mandibular effect.

Surgical treatment of metachronous metastases in different organs following radical nephrectomy

Renal clear cell carcinoma (RCCC) is a neoplasia resistant to radio and chemotherapy, with surgical treatment being the procedure that is recognized for its curative treatment. This case report demonstrates the success of an aggressive surgical treatment for consecutive and late metachronous metastases following radical nephrectomy. Case report: Asymptomatic 50-year old man. During a routine examination, an incidental mass was found by renal ultrasonography. He underwent right radical nephrectomy due to RCCC in June 1992. During the follow-up metastases were evidenced in cerebellum on the seventh year, and in left lung and pancreas on the eighth year following the radical nephrectomy, with all of them successfully treated by surgical excision. Comments: The surgical excision of consecutive and late metachronous metastases in different organs arising from RCCC is feasible, being a good therapeutic alternative in selected cases.