The pain of tendinopathy: physiological or pathophysiological?

Tendon pain remains an enigma. Many clinical features are consistent with tissue disruption—the pain is localised, persistent and specifically associated with tendon loading, whereas others are not—investigations do not always match symptoms and painless tendons can be catastrophically degenerated. As such, the question ‘what causes a tendon to be painful?’ remains unanswered. 

Without a proper understanding of the mechanism behind tendon pain, it is no surprise that treatments are often ineffective. Tendon pain certainly serves to protect the area—this is a defining characteristic of pain—and there is often a plausible nociceptive contributor. However, the problem of tendon pain is that the relation between pain and evidence of tissue disruption is variable. The investigation into mechanisms for tendon pain should extend beyond local tissue changes and include peripheral and central mechanisms of nociception modulation. 

Cross-cultural examination of the structure of the Revised American Pain Society Patient Outcome Questionnaire (APS-POQ-R)

This study investigated the cross-cultural factor stability and internal consistency of the Revised American Pain Society Patient Outcome Questionnaire (APS-POQ-R); a measure of the quality of postoperative pain management employed internationally. We conducted exploratory factor analysis (EFA) of APS-POQ-R data from two point-prevalence studies comprising 268 and 311 surveys of Danish and Australian medical-surgical patients. Parallel analysis indicated four and three factor solutions for Danish and Australian patients respectively, which accounted for 58.1% and 52.9% of variance. Internal consistency was unsatisfactory among both Danish (Cronbach α=.54) and Australian (Cronbach α=.63) cohorts. There was a high degree of between-group similarity in item-factor loadings of variables coded as "pain experience", but not "pain management". This reflected cross-cultural differences in ratings of treatment satisfaction. For Danish patients, satisfaction was associated with the degree of pain severity and activity interference whereas for Australian patients, satisfaction was associated with their perceived ability to participate in treatment. To facilitate further cross-cultural comparison, we compared our findings to past research conducted in the U.S. and Iceland. EFA supported the construct validity of the APS-POQ-R as a measure of "pain experience", but indicated that items measuring "pain management" may vary cross-culturally. Findings highlighted the need for further validation of the APS-POQ-R internationally. PERSPECTIVE: This study revealed the APS-POQ-R as a valid measure of postoperative pain experience for Danish and Australian patients. Measures of patients' perception of pain management were not robust to group differences in treatment expectations and demonstrated cross-cultural instability. Results highlighted difficulties in establishing stable cross-cultural, cross-population subscales for the APS-POQ-R.

Measuring health in a vacuum: examining the disability weight of the DALY

The Disability Adjusted Life Year (DALY) is a widely used summary measure of population health combining years of life lost due to mortality and years of healthy life lost due to disability. A feature of the DALY is that, in the assessment of morbidity, each health condition is associated with a disability weight. The disability weight lies on a scale between 0 (indicating the health condition is equivalent to full health) and 1 (indicating the health condition is equivalent to death). The disability weight associated with each health condition is currently fixed across all social, cultural and environmental contexts. Thus blindness in the United Kingdom has the same disability weight as blindness in Niger in spite of structural interventions in the UK that make the disability less severe than in Niger. Although the fixed disability weight is defended on grounds that it supports a strongly egalitarian flavour in the DALY, we argue that the lack of consideration of realistic contexts results in a measure that will underestimate the burden associated with morbidity in disadvantaged populations and overestimate the burden in advantaged populations. There is, consequently, a loss of information on possible non-clinical points of intervention. Disaggregated estimates of the burden of disease such as those in the World Health Report 2000 should be interpreted with caution.

Stories from beyond the frame dilemas and contradictions of photojournalism in a digitized and globalized world

To engage in the practice of photojournalism is to occupy a position of privilege, because the practice involves entering, albeit for a short while, the lives of others. But with this privilege comes the burden of representation. In this sense I believe that photojournalism is currently in crisis. This crisis concerns the decontextualization of the image in media outlets and the relegation of the photojournalist to the role of merely a hunter/gatherer rather than a storyteller. In other words, photojournalists have become alienated from the process of re-presentation of their own stories. To some extent it has always been thus.

Agreement between adolescent self-report and parent reports of health and well-being: results of an epidemiological study.

Objective To examine parent and adolescent agreement on physical, emotional, mental and social health and well-being in a representative population.
Methodology An epidemiological design was used to obtain parent–child/adolescent dyad data on comparable items and scales of a generic measure of health and well-being, the Child Health Questionnaire (parent/proxy report 50 item, self-report 80 item). Scale analysis included intraclass correlations (ICCs) to examine strength of parent–child associations and independent t-tests for differences between adolescents (with or without an illness). Where there were significant differences in scale scores, analysis of variance and two sample t-tests were used to examine the influence of social, demographic, health concern and school variables. Single items were examined for trends in response categories.
Results 2096 parent–adolescent dyads (adolescent mean age of 15.1 years, males 50%, maternal parent 83.2%, biological parent 93.5%). ICCs were strong. Overall, adolescents reported poorer emotional and social health, and clinically significant differences were observed for perceptions of general health (mean difference 8.1/100), frequency and amount of body pain (5.94/100), experience of mental health (5.14/100), and impact of health on family activities (12.43/100), which widen significantly for adolescents with illness. Social, health and school enjoyment and performance significantly widened parent–child differences.
Conclusions All adolescents were much less optimistic about their health and well-being than their parents, and were only in close agreement on aspects of health and well-being they rated highly. Adolescent reports are more likely to be sensitive to pain, mental health problems, health in general and the impact of their health on family activities.

Cost-effectiveness of cognitive-behavioural therapy and drug interventions for major depression

Objective: Antidepressant drugs and cognitive–behavioural therapy (CBT) are effective treatment options for depression and are recommended by clinical practice guidelines. As part of the Assessing Cost-effectiveness – Mental Health project we evaluate the available evidence on costs and benefits of CBT and drugs in the episodic and maintenance treatment of major depression.

Method: The cost-effectiveness is modelled from a health-care perspective as the cost per disability-adjusted life year. Interventions are targeted at people with major depression who currently seek care but receive non-evidence based treatment. Uncertainty in model inputs is tested using Monte Carlo simulation methods.

Results: All interventions for major depression examined have a favourable incremental cost-effectiveness ratio under Australian health service conditions. Bibliotherapy, group CBT, individual CBT by a psychologist on a public salary and tricyclic antidepressants (TCAs) are very cost-effective treatment options falling below $A10 000 per disability-adjusted life year (DALY) even when taking the upper limit of the uncertainty interval into account. Maintenance treatment with selective serotonin re-uptake inhibitors (SSRIs) is the most expensive option (ranging from $A17 000 to $A20 000 per DALY) but still well below $A50 000, which is considered the affordable threshold.

Conclusions: A range of cost-effective interventions for episodes of major depression exists and is currently underutilized. Maintenance treatment strategies are required to significantly reduce the burden of depression, but the cost of long-term drug treatment for the large number of depressed people is high if SSRIs are the drug of choice. Key policy issues with regard to expanded provision of CBT concern the availability of suitably trained providers and the funding mechanisms for therapy in primary care.

Patients' decision-making strategies for managing postoperative pain

Despite technological advances, many postoperative patients continue to suffer unrelieved pain. The aim of this study was to identify the strategies used by postoperative patients to bring about pain management decisions. A single-group noncomparative study design was chosen using observations as the means of examining pain activities in 2 surgical units of a metropolitan teaching hospital in Melbourne, Australia. A total of 52 nurses and 312 patients participated in the study, and 316 pain activities were observed. The most common strategy used was patients acting as a passive recipient for pain relief (60%), whereas problem solving (23%) and active negotiation (17%) were less commonly used. Patients in this study were admitted for surgical treatment of a particular condition, and their subsequent pain was specifically related to this acute event. Therefore, the lack of familiarity of the situation and the severity of pain experienced may have encouraged passivity. Patients may have also felt uncertain about how to approach the pain decision, preferring to defer to nurses. Because increased pain levels can be associated with fear, patients could have been unwilling to speak with nurses to discuss their need for pain relief.

An individualized psychosocial approach for "treatment resistant" behavioral symptoms of dementia among aged care residents

Background: Behavioral symptoms of dementia are common among residents in mainstream aged care settings, and have a substantial impact on residents and professional caregivers. This study evaluated the impact of individualized psychosocial interventions for behavioral symptoms through a small preliminary study.
Method: Interventions were delivered to a patient group of 31 psychogeriatric aged care residents who presented with behavioral symptoms of dementia that had failed to respond to pharmacological treatment approaches. Outcome data on severity of behaviors, health service utilization and staff burden of care were collected.
Results: A modest but significant reduction in staff ratings of the severity of aggressive and verbally agitated behavioral symptoms was found, with an associated reduction in their perceptions of the burden of caring for these patients. Reduced behavioral disturbance was associated with a reduction in the requirement for primary care consultations, and all participants were able to continue to reside in mainstream aged care facilities, despite an increase in the severity of dementia.
Conclusions: This study supported the use of individualized psychological strategies for behavioral symptoms at all stages of dementia. Methodological limitations of this preliminary study are discussed.

Rehabilitation of Achilles and patellar tendinopathies

Achilles and patellar tendinopathies affect a broad range of the population and are difficult conditions to manage clinically. The pathology is persistent in the chronic tendon and can be considered to be failed healing. The exact cause of tendinopathy pain is unclear but may be related to changes in neurovascular structures.

Rehabilitation for Achilles and patellar tendinopathies is based on an exercise programme that aims to improve muscle–tendon function and normalise the pelvic/lower limb kinetic chain. This incorporates a programme for restoring and improving muscle strength, endurance and power and retraining sport-specific function.

Rehabilitation may take a prolonged period of time, both the athlete and clinician must be patient and persistent to maximise results from an exercise-based treatment.

The DALY, context and the determinants of the severity of disease: an exploratory comparison of paraplegia in Australia and Cameroon

This paper summarises the findings of an empirical investigation of some of the technical and social assumptions on which the disability adjusted life year (DALY) is based. The objectives of the study were to examine the notion that the burden of disease is broadly similar without regard to country, environment, gender or socio-economic status and to develop detailed descriptions of the experiences of the burden of disease as they related to these contextual factors. The study was a multi-factorial exploratory study employing qualitative and quantitative techniques to obtain data on the effects of country (development), environment (urban versus rural), gender and socio-economic status on people with paraplegia. The data provided an extensive and detailed compilation of context rich descriptions of living with paraplegia. Striking features of the data were the differences between countries with respect to the impact of the health conditions on functioning and highlight a context in which paraplegia of like clinical severity can be fatal in one environment and not in another. While there has been some focus on the control of social determinants of disease, there has been little work on the social determinants of the severity of disease. The underlying assumptions of the DALY, which ignore context in the assessment of the burden of disease, risk exacerbating inequalities by undervaluing the burden of disease in less-developed countries. There is a need to continue to subject the development of indicators to rigorous debate to determine a balance between the assumption of a global “average social milieu” and the treatment of each individual as belonging to their own context in the assessment of population health in order for indicators to be meaningful cross-culturally.

Malingering pain in the medicolegal context

Malingering—the willful, deliberate, and fraudulent feigning or exaggeration of illness—was originally described as a means of avoiding military service. In present-day clinical practice, malingering may occur in circumstances where the person wishes to avoid legal responsibility or in situations where compensation or some other benefit might be obtained. In law, the term malingering is used in relation to persons to whom military regulations apply; in other situations, malingering is regarded as fraud and may lead to charges of perjury or criminal fraud. Assertions that an individual is malingering are particularly common in clinical settings where the complaint is of a subjective nature and is not accompanied by objectively demonstrable organic abnormalities. This may occur in relation to complaints of pain in situations where the person is entitled to receive pain-contingent compensation or is suing for damages. In this article, we will review the literature on pain and malingering and discuss attempts that have been made to develop methods and guidelines for the detection of malingered pain. There are, however, no valid clinical methods of assessment of possible malingering of pain. In our view, the ultimate issue of the veracity of the plaintiff is for the Court to decide, and epithets such as “malingerer” have no place in reports prepared for legal purposes by health care professionals.

Nurses' strategies for managing pain in the postoperative setting

Acute pain is a significant problem in the postoperative setting. Patients report a lack of information about pain-control measures and ineffective pain control. Nurses continue to rely on pharmacologic measures and tend to under-administer analgesics. The purpose of this study was to determine the strategies nurses used to manage patients’ pain in the postoperative setting. It also sought to examine the effect of context, including organization of care, nurses’ prioritization of work activities, and pressures during a working shift, on their pain-management strategies. An observational design was used in two surgical units of a metropolitan teaching hospital in Melbourne, Australia. Six fixed observation times were identified as key periods for pain activities, each comprising a 2-hour duration. An observation period was examined at least 12 times, resulting in the completion of 74 observations and the identification of 316 pain cases. Fifty-two nurses were observed during their normal day’s work with postoperative patients. Six themes were identified: managing pain effectively; prioritizing pain experiences for pain management; missing pain cues for pain management; regulators and enforcers of pain management; preventing pain; and reactive management of pain. The findings highlighted the critical nature of communication between clinicians and patients and among clinicians. It also demonstrated the influence of time on management strategies and the relative importance that nurses place on nonpharmacologic measures in actual practice. This research, which portrays what happens in actual clinical practice, has facilitated the identification of new data that were not evident from other research studies.

Measuring the impact of intimate partner violence on the health of women in Victoria, Australia

Objective: Using burden of disease methodology, estimate the health risks of intimate partner violence (IPV) among women in Victoria, Australia.

Methods: We calculated population attribute fractions (from survey data on the prevalence of IPV and the relative risks of associated health problems in Australia) and determined health outcomes by applying them to disability-adjusted life year estimates for the relevant disease and injury categories for Victoria, Australia for 2001.

Findings: For women of all ages IPV accounted for 2.9% (95% uncertainty interval 2.4-3.4%)  of the total disease and injury burden.  Among women 18-44 years of age, IPV was associated with 7.9% (95% uncertainty interval 6.4-935%) of the overall disease burden and was a larger risk to health than risk factors traditionally included in burden of disease studies, such as raised blood pressure, tobacco use and increased body weight.  Poor mental health contributed 73% and substance abuse 22% to the disease burden attributed to IPV.

Conclusion: Our findings suggest that IPV constitutes a significant risk to women's health.  Mental health policy-makers and health workers treating common mental health problems need to be aware that IPV is an important factor.  Future research should concentrate on evaluating effective interventions to prevent women being exposed to violence, and identifying the most appropriate mental health care for victims to reduce short- and long-term disability

Measurement of the economic impact of visual impairment from age-related macular degeneration in Australia

The purpose of this report was to: (i) outline the potential value of health economic studies into age-related macular degeneration (AMD); (ii) provide an overview of health economic studies pertinent to AMD; and (iii) outline the basic frame work of cost-of-illness studies (a useful first step in applying economic methods). The detection and management of sensory loss in the elderly plays a key role in the Australian Government's Healthy Ageing Strategy. Age-related macular degeneration is currently the leading cause of blindness in elderly Australians. Although a large proportion of AMD cases remain untreatable, the introduction of photo­dynamic therapy provides a relatively expensive and possibly cost-effective innovation for others. Antioxidant therapy has also been proven effective in reducing progression of early to late disease. The discipline of economics can contribute to an understanding of AMD prevention and treatment through: (i) describing the current burden of disease; (ii) predicting the changes in the burden of disease over time, and (iii) evaluating the efficiency of different interventions. Cost-of-illness studies have been performed in many fields of medicine. Little work, however, has been done on describing the economic impact from AMD. A number of different economic evaluation methods can be used in judging the efficiency of possible interventions to reduce the disease burden of AMD. Although complementary in nature, each has specific uses and limitations. Studies of the economic impact of eye diseases are both feasible and necessary for informed health care decision-making.

Close, but still too far: the experience of Australian people with cancer commuting from a regional to a capital city for radiotherapy treatment

This paper reports the findings of a study undertaken in November 2001 on the experiences of 17 rural people from the regional city of Toowoomba who had been diagnosed with cancer and were required to travel to the capital city of Queensland (Brisbane) for radiotherapy. The interviews were tape recorded; the recordings were transcribed verbatim and analysed for emergent themes and subthemes, following verification by the participants that the transcription was a true record of their experience. The major themes that arose from the study were (1) the burden of travel; (2) the difficulties of living in accommodation that is not one's own home; (3) the financial burden caused by the need to relocate or travel to and from Brisbane; (4) the lack of closeness to family and friends; (5) and feelings of being a burden on others. The findings suggest that at a time of stress, an increasing burden is placed on cancer clients and their families if they are required to travel for radiotherapy. Health professionals who read the results of this study should be aware of the isolation of rural people who have to live in an unfamiliar environment at a time of great stress. Support mechanisms should be put into place in these referral centres to deal with these stressors.