Disability in Iowa: Public Health Needs Assessment

According to the Centers for Disease Control and Prevention (CDC), the number of adults reporting a disability is expected to increase, along with the need for appropriate medical and public health services. People with disabilities (PWD) face many barriers to good heath, including having overall poorer health, less access toadequate health care, limited access to health insurance, skipping mediacl care because of cost, and engaging in risky health behaviors including smoking and physical inactivity. The goals of the Iowa public health needs assessment were to assess the burden of disability in Iowa counties including health risk factors such as chronic conditions, determine access to preventive health care, and determine the effect of socioeconomic conditions. The state level assessment was based on th 2009-2012 American Community Survey (ACS) and publiccally available Behavioral Risk FactorSurveillance System (BRFSS) 2011 survey. The 2001-2010 combined BRFSS data was used for county level assessment. The needs assessment led us to conclude that adult Iowans with idsabilities face several challenges compared to non-disabled adults. They are more likely to suffer from debilitating chronic conditions and social disparities. Counties with the higher levels of poverty were more likely to have PWD with higher levels of disability related disparities.

La communication de la douleur et de l'incapacité au sein des couples dont l'un des partenaires souffre de douleur persistante

Au cours des dernières années, il a été démontré que la façon dont la douleur est communiquée, par l’entremise de comportements de douleur, est associée à l’incapacité auto-rapportée et à la trajectoire de chronicité des individus souffrant de douleur persistante. Cependant, très peu de recherches ont investigué le lien entre la perception de la douleur dans le couple et la trajectoire de chronicité des individus souffrant de douleur persistante. Dans le cadre de cette thèse, trois études ont été réalisées afin de mieux comprendre les facteurs impliqués dans la communication de la douleur au sein de couples dont l’un des partenaires souffrait de douleur persistante. Une première étude a été réalisée afin de valider une version francophone du « Pain Disability Index (PDI) », un questionnaire développé pour évaluer l’incapacité reliée à la douleur persistante. Comme attendu, les résultats indiquent que cette version du PDI reproduit la structure factorielle de la version originale du PDI et présente une bonne fidélité et validité. Une autre étude a été réalisée auprès de couples dont l’un des partenaires souffre de douleur persistante afin d’évaluer les corrélats de la justesse empathique, d’explorer la relation entre la justesse empathique reliée à la douleur et différentes variables associées à l’adaptation du patient et du conjoint et enfin d’explorer la relation entre la justesse empathique reliée à la douleur et des variables relationnelles. Les résultats suggèrent que de façon générale, la justesse empathique est associée à des résultats négatifs chez les patients souffrant de douleur persistante et ne semble pas un corrélat important de la satisfaction conjugale. Enfin, une dernière étude a été réalisée afin de comprendre l’influence de la concordance des pensées catastrophiques dans le couple sur l’émission de comportements de douleur et sur la perception de la douleur et de l’incapacité lors d’une tâche physiquement exigeante. Il a été trouvé que les participants ayant un niveau élevé de pensées catastrophiques, qui étaient en relation avec un conjoint ayant un faible niveau de pensées catastrophiques, ont émis plus de comportements de douleur que tous les autres groupes. Ces résultats suggèrent que les personnes souffrant de douleur persistante ayant un niveau élevé de pensées catastrophiques peuvent avoir besoin d’augmenter le « volume » de la communication de la douleur afin de compenser pour la tendance des conjoints ayant un faible niveau de pensées catastrophiques à sous-estimer les signaux de douleur. En résumé, puisque l’émission de comportements de douleur est associée à l’incapacité auto-rapportée des individus souffrant de douleur persistante, il est possible que toute situation qui contribue à une augmentation des comportements de douleur, contribuera également à un niveau d’incapacité plus élevé. Ainsi, d’un point de vue clinique, les interventions qui amènent le conjoint à faire de l’écoute active et à valider la personne souffrante, pourraient réduire la présence des comportements de douleur et potentiellement avoir un impact sur le niveau d’incapacité des personnes souffrant de douleur persistante.

The neurobiology of meditation for the control of pain

La douleur est une expérience multidimensionnelle comportant des aspects sensoriels, émotionnels et cognitifs. Il a été montré que cette expérience peut être modulée par des facteurs psychologiques ou des interventions cognitives comme l’attention, la distraction, l’hypnose ou les attentes. La tradition orientale suggère également que la pratique de la méditation pourrait avoir des effets analgésiques. D’un point de vue théorique, plusieurs mécanismes pourraient expliquer ces effets. Cependant, très peu d’études ont testé ces hypothèses. Les études présentées dans cette thèse avaient donc pour objectif d’examiner les mécanismes analgésiques de la méditation. Dans un premier temps, une étude psychophysique a été réalisée afin de comparer les réponses à la douleur entre des adeptes de la méditation Zen et des sujets contrôles, dans différentes conditions attentionnelles. Durant la condition attentionnelle de type « mindful », les adeptes de la méditation ont présenté une plus faible sensibilité à la douleur, des réponses attentionnelles à la douleur atypiques et une diminution de la perception de la douleur associée à l’entraînement à la méditation. Une deuxième étude a été réalisée en imagerie par résonance magnétique fonctionnelle (IRMf) avec des groupes de participants similaires. Dans une condition sans méditation, les adeptes de la méditation ont présenté de plus fortes réponses nociceptives dans les régions primaires de la douleur. Les régions cérébrales associées aux processus d’évaluation, à la mémoire et aux émotions ont quant à elles montré une diminution d’activité. De plus, cette diminution était plus importante chez les adeptes de la méditation les plus expérimentés et elle était associée à des évaluations de douleur plus faibles. Par ailleurs, des changements de connectivité fonctionnelle entre le cortex préfrontal et une région primaires de la douleur étaient associés à la sensibilité à la douleur chez les adeptes de la méditation. Finalement, une étude d’imagerie cérébrale structurale (publiée comme deux études séparées) a été réalisée pour examiner les différences d’épaisseur corticale entre les groupes, pour des régions associées à la douleur. Les adeptes de la méditation ont présenté une épaisseur plus importante de matière grise dans plusieurs régions associées à la douleur et l’attention. De plus, ces différences étaient associées à une mesure expérientielle de l’attention, à la sensibilité à la douleur et à l’expérience de méditation. Dans l’ensemble, ces résultats suggèrent que la méditation pourrait influencer la perception de la douleur par des changements fonctionnels et physiques dans le cerveau. De plus, le patron d’activation et la modulation de l’expérience paraissent uniques en comparaison à ceux d’autres interventions, ce qui suggère qu’un état de détachement et un focus mental favorisent la dissociation entre les aspects désagréables et sensoriels d’un stimulus nociceptif.

Disability is in the Eye of the Beholder

Travail créatif / Creative Work

Os distúrbios osteomusculares e suas consequências para os profissionais da odontologia

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES)

Central poststroke pain: somatosensory abnormalities and the presence of associated myofascial pain syndrome

Background: Central post-stroke pain (CPSP) is a neuropathic pain syndrome associated with somatosensory abnormalities due to central nervous system lesion following a cerebrovascular insult. Post-stroke pain (PSP) refers to a broader range of clinical conditions leading to pain after stroke, but not restricted to CPSP, including other types of pain such as myofascial pain syndrome (MPS), painful shoulder, lumbar and dorsal pain, complex regional pain syndrome, and spasticity-related pain. Despite its recognition as part of the general PSP diagnostic possibilities, the prevalence of MPS has never been characterized in patients with CPSP patients. We performed a cross-sectional standardized clinical and radiological evaluation of patients with definite CPSP in order to assess the presence of other non-neuropathic pain syndromes, and in particular, the role of myofascial pain syndrome in these patients. Methods: CPSP patients underwent a standardized sensory and motor neurological evaluation, and were classified according to stroke mechanism, neurological deficits, presence and profile of MPS. The Visual Analogic Scale (VAS), McGill Pain Questionnaire (MPQ), and Beck Depression Scale (BDS) were filled out by all participants. Results: Forty CPSP patients were included. Thirty-six (90.0%) had one single ischemic stroke. Pain presented during the first three months after stroke in 75.0%. Median pain intensity was 10 (5 to 10). There was no difference in pain intensity among the different lesion site groups. Neuropathic pain was continuous-ongoing in 34 (85.0%) patients and intermittent in the remainder. Burning was the most common descriptor (70%). Main aggravating factors were contact to cold (62.5%). Thermo-sensory abnormalities were universal. MPS was diagnosed in 27 (67.5%) patients and was more common in the supratentorial extra-thalamic group (P <0.001). No significant differences were observed among the different stroke location groups and pain questionnaires and scales scores. Importantly, CPSP patients with and without MPS did not differ in pain intensity (VAS), MPQ or BDS scores. Conclusions: The presence of MPS is not an exception after stroke and may present in association with CPSP as a common comorbid condition. Further studies are necessary to clarify the role of MPS in CPSP.

Incapacidade relacionada à dor lombar crônica: prevalência e fatores associados

A incapacidade relacionada à dor lombar crônica (DLC) é um fenômeno complexo e multifatorial. O objetivo desse estudo foi identificar a prevalência e os fatores associados à incapacidade em pacientes com dor lombar crônica. Estudo transversal com amostra composta por 177 pacientes com DLC, de três serviços de saúde; que responderam ao formulário com dados demográficos, ao Inventário de Depressão de Beck, às Escalas Oswestry Disability Index, de autoeficácia para dor crônica, Tampa de Cinesiofobia e de Fadiga de Piper. A prevalência de incapacidade foi de 65% (IC95%: 57,5 - 72,0) e era de moderada a grave em 80,7% dos pacientes. O modelo de regressão múltipla identificou três fatores independentemente associados à incapacidade: ausência de trabalho remunerado, autoeficácia baixa e depressão. Os fatores associados à incapacidade identificados são modificáveis. Intervenções como recolocação no trabalho, tratamento para a depressão e reconceitualização da crença de autoeficácia podem ter um impacto importante na prevenção e redução de incapacidade.

Cultural and migration aspects in functional abdominal pain

Compared to Europe's mean immigrant contingent of 7.3 to 8.6 % Switzerland holds the highest contingent of foreign population with 23.5 %. Therefore it is of utmost importance that physicians have a knowledge of the specific characteristics of immigrant patients. The influence of personality factors (experience, behavior) is not independent from the influence of culturally-related environmental factors (regional differences in diet, pollutants, meanings, etc.). In addition, different cultural groups rate their quality of life differently. Psychological reasons for recurrent abdominal pain are stress (life events), effects of self-medication (laxatives, cocaine) and sexual abuse but also rare infectious diseases are more common among immigrants (e.g. tuberculosis, histoplasmosis, etc.). Migration-specific characteristics are mainly to find in the semiotics of the symptoms: not every abdominal pain is real pain in the abdomen. Finally, it is crucial to make the distinction between organic, functional and psychological-related pain. This can, however, usually only be accomplished in the context of the entire situation of a patient and, depending on the situation, with the support of a colleague from the appropriate cultural group or an experienced interpreter. In this review we limit ourselves to the presentation of the working population of the migrants, because these represent the largest group of all migrants. The specific situation of asylum seekers will also be refrained to where appropriate.

Determining appropriate measurement methods for etiological research of computing-related musculoskeletal symptoms and disorders

Two studies among college students were conducted to evaluate appropriate measurement methods for etiological research on computing-related upper extremity musculoskeletal disorders (UEMSDs). ^ A cross-sectional study among 100 graduate students evaluated the utility of symptoms surveys (a VAS scale and 5-point Likert scale) compared with two UEMSD clinical classification systems (Gerr and Moore protocols). The two symptom measures were highly concordant (Lin's rho = 0.54; Spearman's r = 0.72); the two clinical protocols were moderately concordant (Cohen's kappa = 0.50). Sensitivity and specificity, endorsed by Youden's J statistic, did not reveal much agreement between the symptoms surveys and clinical examinations. It cannot be concluded self-report symptoms surveys can be used as surrogate for clinical examinations. ^ A pilot repeated measures study conducted among 30 undergraduate students evaluated computing exposure measurement methods. Key findings are: temporal variations in symptoms, the odds of experiencing symptoms increased with every hour of computer use (adjOR = 1.1, p < .10) and every stretch break taken (adjOR = 1.3, p < .10). When measuring posture using the Computer Use Checklist, a positive association with symptoms was observed (adjOR = 1.3, p < 0.10), while measuring posture using a modified Rapid Upper Limb Assessment produced unexpected and inconsistent associations. The findings were inconclusive in identifying an appropriate posture assessment or superior conceptualization of computer use exposure. ^ A cross-sectional study of 166 graduate students evaluated the comparability of graduate students to College Computing & Health surveys administered to undergraduate students. Fifty-five percent reported computing-related pain and functional limitations. Years of computer use in graduate school and number of years in school where weekly computer use was ≥ 10 hours were associated with pain within an hour of computing in logistic regression analyses. The findings are consistent with current literature on both undergraduate and graduate students. ^

What individuals with rheumatic diseases know about the Americans with Disabilities Act: A survey

Individuals with rheumatic diseases often have disabilities which limit one or more major life activity. Common disabilities among individuals with rheumatic illnesses such as chronic pain, hand deformities, and fatigue may be hidden. With a hidden disability, an individual may be unaware that he or she could qualify as disabled under the Americans with Disabilities Act (ADA). The ADA provides for reasonable accommodation for qualified individuals with disability related limitations. Accommodations under the ADA are designed to remove barriers preventing full participation in society, including employment, for individuals with disability related limitations.^ The primary objective of this study was to determine the knowledge level of individuals with rheumatic conditions about the Americans with Disabilities Act (ADA). One hundred and seven individuals with various rheumatic illnesses participated in this survey. The forty question survey included questions about type of rheumatic condition, employment, pain level, and knowledge of the ADA. Results of this study show that individuals with rheumatic conditions are more familiar with general information about the ADA and less familiar with specific information. The longer an individual has been diagnosed with a rheumatic condition the more he or she knows about the ADA. Common sources of information about the ADA are media and networking with others, rather than health care professionals. The recommendation for occupational therapists is to include education about the ADA as an integral component of treatment for all individuals with rheumatic conditions. ^

Dolor osteo-muscular y factores asociados en el personal de enfermería de un centro hospitalario de alta complejidad en Colombia

Antecedentes: Los trastornos musculo-esqueléticos son una de las primeras causas de ausentismo laboral y afectan con mayor frecuencia columna y miembros. El personal de enfermería está expuesto a riesgo biomecánico superior dado por la manipulación manual de pacientes. Estimar la magnitud de asociación entre dolor osteo-muscular y carga biomecánica por movilización de pacientes en personal de enfermería y, los factores que modifican tal efecto, es de gran importancia en el ámbito laboral en busca de estrategias de prevención de enfermedades de origen laboral. Objetivo: determinar los factores predictores de dolor osteo-muscular en trabajadores de enfermería en un centro hospitalario de alta complejidad. Materiales y métodos: Estudio analítico transversal, en el que participaron 141 personas, quienes otorgaron su consentimiento informado. Los criterios de inclusión fueron: edad≥ 18 años, estudiantes, practicantes, auxiliares y jefes de enfermería asistenciales de salas de cirugía y hospitalización, antigüedad mínima de 2 meses en el cargo. Se utilizaron como criterios de exclusión: personal de enfermería en cargos administrativos y de las áreas de urgencias y cuidados intensivos, trabajadores con diagnóstico establecido artrosis, osteoartritis o artritis reumatoide, mujeres gestantes. Para lograr los objetivos aplicó el Cuestionario Nórdico, el cuestionario internacional de actividad física IPAQ y la metodología MAPO. Resultados: La frecuencia global de dolor osteo-muscular en el último año fue de 55%, implicando más frecuentemente columna lumbar, columna dorsal y miembro superior. Se evaluaron los servicios de onco-hematología, hospitalización y salas de cirugía y las clasificaciones de MAPO fueron medio a alto, no hubo áreas con riesgo irrelevante. Mediante análisis de regresión logística multivariada, se pudo determinar que los principales predictores de dolor osteo-muscular son trabajar en un área con MAPO nivel alto (OR=2,236, con respecto a MAPO medio) y en el turno de la mañana (OR=2,355, con respecto a turno en la tarde/noche).

Improving maximum walking distance in early peripheral arterial disease: Randomised controlled trial

The purpose of this study was to determine the impact of increased physical activity and cessation of smoking on the natural history of early peripheral arterial disease, We conducted a randomised controlled trial in Perth, Western Australia, involving 882 men with early peripheral arterial disease identified via population-based screening using the Edinburgh Claudication Questionnaire and the ankle:brachial index. Members of the control group (n = 441) received usual care from their general practitioner while members of the intervention group (n = 441) were allocated to a stop smoking and keep walking regime - a combined community-based intervention of cessation of smoking (where applicable) and increased physical activity. Postal follow-up occurred at two and 12 months post-entry into the trial. The main outcome of interest was maximum walking distance. There were no statistically significant differences in the characteristics of the intervention and usual care groups at recruitment. Follow-up information at two and 12 months was available for 85% and 84% of participants, respectively. At 12 months, more men allocated to the intervention group had improved their maximum walking distance (23% vs 15%; chi(2) = 9.74, df = 2, p = 0.008). In addition, more men in the intervention group reported walking more than three times per week for recreation (34% vs 25%, p = 0.01). Although not statistically significant, more men in the intervention group who were smokers when enrolled in the trial had stopped smoking (12% vs 8%, p = 0.43). It is concluded that referral of older patients with intermittent claudication to established physiotherapy programs in the community can increase levels of physical activity and reduce disability related to peripheral arterial disease. A combination of simple and safe interventions that are readily available in the community through physiotherapists and general practitioners has the potential to improve early peripheral arterial disease.

Comparative Study of Analgesic Effectiveness Using Three Different Anesthetic Techniques for Intravitreal Injection of Bevacizumab

BACKGROUND AND OBJECTIVE: To compare the analgesic effectiveness and aesthetic appearance associated with topical, subconjunctival, and peribulbar anesthesia for intravitreal bevacizumab injection. PATIENTS AND METHODS: Sixty consecutive patients undergoing their first intravitreal bevacizumab injection were randomized to receive one of three forms of anesthesia: proxymetacaine eye drops, subconjunctival injection of 2% xylocaine, and peribulbar injection of 2% xylocaine. Pain associated with the intravitreal injection and with the entire procedure (including anesthesia administration) was recorded using a Visual Analog Scale 15 minutes after intravitreal injection. Anterior segment evaluation was performed 24 hours after injection to measure the number of clock hours of subconjunctival hemorrhage. RESULTS: Median injection-related pain score was significantly lower in the peribulbar group compared with the topical and subconjunctival groups (P < .05). Median entire procedure pain score was significantly higher In the peribulbar group compared with the topical and subconjunctival groups (P < .05). The median extent of subconjunctival hemorrhage was significantly lower in the topical group compared with the other groups (P < .05). CONCLUSION: Among the three anesthetic techniques, peribulbar anesthesia was associated with greater effectiveness in controlling injection-related pain but was least effective in controlling entire procedure pain. There was no significant difference in pain scores between the topical and subconjunctival groups, and topical anesthesia was associated with less subconjunctival hemorrhage.

Vulvar Lichen Sclerosus: Efficacy of Photodynamic Therapy Under Conscious Sedation with Inhaled 50% Nitrous Oxide and Oxygen Mixture

Anogenital lichen sclerosus is a chronic, inflammatory, mucocutaneous disorder of significant morbidity. Common symptoms include pruritus, pain, dysuria, and dyspareunia, frequently of difficult control. Photodynamic therapy (PDT) may be an effective therapeutic option in selected cases refractory to first--‐line treatment options. However, procedure--‐related pain is a limiting factor in patient adherence to treatment. Conscious sedation and analgesia with a ready--‐to--‐use gas mixture of nitrous oxide and oxygen is useful in short--‐term procedures. It provides a rapid, effective, and short--‐lived effect, without the need for anesthesiology support. A 75--‐year--‐old woman presented with a highly symptomatic, histologically confirmed vulvar lichen sclerosus, with at least 15 years of evolution. Pain, pruritus, and dysuria were intense and disabling. Treatment with ultrapotent topical corticosteroids proved to be ineffective despite patient compliance. She was then referred for PDT. A total of 3 sessions were performed, held at a mean interval of 9 weeks, and under the analgesic and sedative effect of nitrous oxide/oxygen gas. Response to treatment was evaluated through a daily, self--‐reported pain rating scale. Dysuria remitted completely after the first PDT session. An 80% reduction in pruritus and pain was observed after the third session, and has been sustained for the past six months without further need for topical corticotherapy. Treatment sessions were well tolerated and pain-- free, with no side effects to report. PDT appears to be effective in the symptomatic treatment of vulvar lichen sclerosus. To the authors’ knowledge this is the first case reporting the use of inhaled nitrous oxide/oxygen gas mixture during PDT performed in the genital area. Its analgesic and sedative effects may increase patients’ adherence to this painful procedure. Furthermore, given its safety, it can be easily managed in outpatient clinics by trained dermatologists.

Conscious Sedation with Inhaled 50% Nitrous Oxide/Oxygen Premix in Photodynamic Therapy Sessions for Vulvar Lichen Sclerosus Treatment

Photodynamic therapy has been described as an effective therapeutic option in selected cases of anogenital lichen sclerosus that are refractory to first-line treatments. However, procedure-related pain is a limiting factor in patient adherence to treatment. The authors report the case of a 75-year-old woman with highly symptomatic vulvar lichen sclerosus, successfully treated with photodynamic therapy. An inhaled 50% nitrous oxide/oxygen premix was administered during sessions, producing a pain-relieving, anxiolytic, and sedative effect without loss of consciousness. This ready-to-use gas mixture may be a well-tolerated and accepted alternative to classical anesthetics in Photodynamic therapy, facilitating patients' adherence to illumination of pain-prone areas.