Bases teóricas dos processos de medicalização: um olhar sobre as forças motrizes

Introdução: O tema medicalização emerge como objeto de estudo no campo da sociologia da saúde, a partir da década de 70, nas vozes de Irving Zola, Ivan Illich, Peter Conrad e Michel Foucalt; as quais indicaram a crescente influência da medicina em campos que até então não lhe pertenciam. E, no decorrer dos anos, o termo vem sendo apropriado por vários campos: na saúde, na educação, na psicologia, entre outros. Esta configuração levou alguns estudiosos da primeira década do século XXI, a se preocupar com o uso impreciso e vago do conceito de medicalização na produção científica. Neste sentido, este estudo busca olhar para os processos de medicalização, tomando-o em sua pluralidade a fim de discernir as principais forças motrizes e coteja-las com as mudanças na contemporaneidade. Objetivo: Recuperar as forças motrizes contidas nas principais contribuições dos autores primários sobre os processos de medicalização. Método: Realizou-se um exercício hermenêutico composto pelos seguintes passos: leitura profunda do texto, fichamento dos aspectos centrais que caracterizam as diversas concepções sobre medicalização. Interpretação do conteúdo por meio da abstração dos núcleos de sentido e dos referenciais teóricos que lhe dão suporte. Resultados: A partir deste movimento reflexivo e crítico conseguiu-se desvelar quatro conceitos nucleares que representam as principais forças motrizes: a indústria, as instituições, o Estado e a sociedade. Zola oferece indícios que o Estado e a indústria teriam levado a sociedade à dependência da medicina. Para Illich, a medicina, por si só, detém o poder comparada as outras instituições. Para Michel Foucault, a medicina deixou de ser uma ciência pura e transformou-se numa instituição subordinada a um sistema econômico e de poder, enfim a uma lógica subjacente aos princípios e regras de governo. Em contrapartida, para Conrad a medicalização não constitui um empreendimento exclusivo da medicina, prevalecendo os interesses de outras instituições e organizações sociais. O sentido com que cada um desses conceitos é usado difere entre os autores e a distinção desses aspectos é chave para compreender a contribuição efetiva de cada um. Da mesma forma, ocorre quando os autores discutem as consequências e os efeitos causados pelos processos de medicalização. Alguns autores direcionam seus efeitos para os indivíduos, num processo de exacerbação da individualização; enquanto que outros focam os efeitos da medicalização nas políticas de saúde e na questão econômica associada ao oneroso custo financeiro para a sociedade e o país. Considerações finais: A recuperação e a compreensão dos significados subjacentes às principais forças motrizes presentes nas contribuições de cada autor apresentadas nesta investigação constituem-se em passo importante para subsidiar a reflexão sobre processos concretos de medicalização no início do século XXI, um período marcado por aceleradas transformações, no qual, entre outros aspectos, a medicina e várias instituições têm sido crescentemente, capturadas para satisfazer, de um lado o consumismo, e de outro, a avidez pelo lucro do mercado capitalista; ao mesmo tempo em que forças desagregadoras atravessam os sujeitos impactando sua autonomia e identidade política, social e econômica.

Undermining patient and public engagement and limiting its impact:the consequences of the Health and Social Care Act 2012 on collective patient and public involvement

Patient and public involvement has been at the heart of UK health policy for more than two decades. This commitment to putting patients at the heart of the British National Health Service (NHS) has become a central principle helping to ensure equity, patient safety and effectiveness in the health system. The recent Health and Social Care Act 2012 is the most significant reform of the NHS since its foundation in 1948. More radically, this legislation undermines the principle of patient and public involvement, public accountability and returns the power for prioritisation of health services to an unaccountable medical elite. This legislation marks a sea-change in the approach to patient and public involvement in the UK and signals a shift in the commitment of the UK government to patient-centred care. © 2013 John Wiley & Sons Ltd.

Psychological predictors of injury among elite athletes

Objectives: To establish injury rates among a population of elite athletes, to provide normative data for psychological variables hypothesised to be predictive of sport injuries, and to establish relations between measures of mood, perceived life stress, and injury characteristics as a precursor to introducing a psychological intervention to ameliorate the injury problem. Methods: As part of annual screening procedures, athletes at the Queensland Academy of Sport report medical and psychological status. Data from 845 screenings (433 female and 412 male athletes) were reviewed. Population specific tables of normative data were established for the Brunel mood scale and the perceived stress scale. Results: About 67% of athletes were injured each year, and about 18% were injured at the time of screening. Fifty percent of variance in stress scores could be predicted from mood scores, especially for vigour, depression, and tension. Mood and stress scores collectively had significant utility in predicting injury characteristics. Injury status (current, healed, no injury) was correctly classified with 39% accuracy, and back pain with 48% accuracy. Among a subset of 233 uninjured athletes (116 female and 117 male), five mood dimensions (anger, confusion, fatigue, tension, depression) were significantly related to orthopaedic incidents over the preceding 12 months, with each mood dimension explaining 6–7% of the variance. No sex differences in these relations were found. Conclusions: The findings support suggestions that psychological measures have utility in predicting athletic injury, although the relatively modest explained variance highlights the need to also include underlying physiological indicators of allostatic load, such as stress hormones, in predictive models.

Psychological screening and injury among elite athletes

The purpose of the present investigation was to evaluate the effectiveness of the psychological component of the Queensland Academy of Sport (QAS) Health Screening Questionnaire in screening for injury/illness characteristics among elite athletes. In total, 793 scholarship athletes (409 females and 384 males) ranging in age from 11 to 41 years (M = 19, SD = 4.4) across 20 sports at the QAS in Brisbane, Australia, completed the QAS Health Screening Questionnaire. Psychological risk factors examined were life stress and mood, as measured by the Perceived Stress Scale - 10 (PSS-10) and the Brunel Mood Scale (BRUMS) respectively, in addition to disordered eating behaviours and history of diagnosed psychological disorders. Medical risk factors examined included asthma and back pain. Single-factor MANOVAs showed multivaritate effects for injury, second injury, back pain, asthma, anxiety disorder diagnosis, and fasting. Discriminant function analyses demonstrated that life stress and mood scores had significant utility in correctly classifying injury and second injury status, asthma, back pain, anxiety, and eating disorder diagnosis, in addition to the use of fasting and vomiting as weight control methods. The present findings suggest that the psychology component of the QAS Health Screening Questionnaire demonstrates significant utility as a screening tool regarding injury/illness characteristics among elite athletes.

Psychological predictors of injury in elite athletes

The Queensland Academy of Sport (QAS) supports over 600 high-level athletes across 20 sports. Given the high cost of injuries (e.g., time out of sport and consequent detraining, expense of rehabilitation, adverse social and economic effects), comprehensive injury management and prevention has become a priority for the QAS. Considering the potential for developing cost-effective, preventative programs, knowledge gained by examination of psychological screening predictors of injury may also prove beneficial for the broader sports medicine community. Aims were to: Objectively summarise existing injury characteristics, including the creation of population-specific norms for scholarship holders at the QAS. Assess relationships between injuries, specific medical factors (e.g., asthma, back pain) and psychological risk factors including life stress, mood, previous psychological diagnoses and disordered eating behaviour over a three-year period. Evaluate the effectiveness of the psychological component of the QAS Health Screening Questionnaire.

Acute injuries in track and field athletes: A 3-year observational study at the Penn Relays Carnival with epidemiology and medical coverage implications

Background Few studies have examined acute injuries in track and field in both elite and sub-elite athletes. Purpose To observe the absolute and relative rates of injury in track and field athletes across a wide range of competition levels and ages during three years of the Penn Relays Carnival to assist with future medical coverage planning and injury prevention strategies. Study design: Descriptive epidemiology study. Methods Over a 3-year period all injuries treated by the medical staff were recorded on a standardised injury report form. Absolute injury rates (absolute number of injuries) and relative injury rates (number of injuries per 1000 participants) were determined and odds ratios (OR) of injury rates were calculated between sexes, competition levels and events. Injuries were also broken down into major or minor medical or orthopedic injuries. Results Throughout the study period 48,473 competing athletes participated in the Penn Relays Carnival, and 436 injuries were sustained. For medical coverage purposes, the relative rate of injury subtypes was greatest for minor orthopedic injuries (5.71 injuries per 1000 participants), followed by minor medical injuries (3.42 injuries per 1000 participants), major medical injuries (0.69 injuries per 1000 participants) and major orthopedic injuries (0.18 injuries per 1000 participants). College/elite level athletes displayed the lowest relative injury rate (7.99 injuries per 1000 participants), which was significantly less than high school (9.87 injuries per 1000 participants) and masters level athletes (16.33 injuries per 1000 participants). Males displayed a greater likelihood of suffering a minor orthopedic injury compared to females (OR = 1.36, 95% CI = 1.06 to 1.75; χ2 = 5.73, p = 0.017) but were less likely to sustain a major medical injury (OR = 0.33, 95% CI = 0.15 to 0.75; χ2 = 7.75, p = 0.005). Of the three most heavily participated in events, the 4 x 400m relay displayed the greatest relative injury rate (13.6 injuries per 1000 participants) compared to the 4 x 100 and 4 x 200m relay. Conclusions Medical coverage teams for future large scale track and field events need to plan for at least two major orthopedic and seven major medical injuries per 1000 participants. Male track and field athletes, particularly masters level male athletes, are at greater risk of injury compared to other genders and competition levels.

Short biceps femoris fascicles and eccentric knee flexor weakness increase the risk of hamstring injury in elite football (soccer): A prospective cohort study

Background/Aim: To investigate the role of eccentric knee flexor strength, between-limb imbalance and biceps femoris long head (BFlh) fascicle length on the risk of a future hamstring strain injury (HSI). Methods: Elite soccer players (n=152) from eight different teams participated. Eccentric knee flexor strength during the Nordic hamstring exercise and BFlh fascicle length were assessed at the beginning of pre-season. The occurrences of a HSI following this were recorded by the team medical staff. Relative risk (RR) was determined for univariate data, and logistic regression was employed for multivariate data. Results: Twenty-seven new HSIs were reported. Eccentric knee flexor strength below 337N (RR = 4.4; 95% CI = 1.1 to 17.5) and BFlh fascicles shorter than 10.56cm (RR = 4.1; 95% CI=1.9 to 8.7) significantly increased the risk of a subsequent HSI. Multivariate logistic regression revealed significant effects when combinations of age, previous history of HSI, eccentric knee flexor strength and BFlh fascicle length were explored. From these analyses the likelihood of a future HSI in older athletes or those with a previous HSI history was reduced if high levels of eccentric knee flexor strength and longer BFlh fascicles were present. Conclusions: The presence of short BFlh fascicles and low levels of eccentric strength in elite soccer players increase the risk of a future HSI. The greater risk of a future HSI in older players or those with a previous HSI is reduced when they possess longer BFlh fascicles and high levels of eccentric strength.

LA Size in Former Elite Athletes

A recent meta-analysis by Iskandar et al. (1) nicely showed that endurance athletes have larger left atrial (LA) diameters compared with control subjects. Yet only 9 of 54 studies included in their analysis reported LA volume values corrected for body surface area (BSA). In fact, few studies have determined LA volume in young athletes, and, to the best of our knowledge, no study has reported this variable in older athletes. This is an important question given the growing debate about the potential deleterious effects of long-term strenuous endurance exercise on the human heart, notably the higher risk of atrial fibrillation (AF), a condition for which both atrial dilation and the normal aging process are thought to be potential causative mechanisms (2). Thus, we aimed to assess the long-term consequences of endurance exercise on LA volume in athletes who were highly competitive at younger ages and are still active. To this end, we compared BSA-corrected LA volumes determined with late gadolinium enhancement magnetic resonance imaging (LGE-MRI) in former elite endurance athletes and sedentary control subjects.

Physiological demands of competitive elite cross-country skiing

Introduction Researchers have, for decades, contributed to an increased collective understanding of the physiological demands in cross-country skiing; however, almost all of these studies have used either non-elite subjects and/or performances that emulate cross-country skiing. To establish the physiological demands of cross-country skiing, it is important to relate the investigated physiological variables to the competitive performance of elite skiers. The overall aim of this doctoral thesis was, therefore, to investigate the external validity of physiological test variables to determine the physiological demands in competitive elite cross-country skiing. Methods The subjects in Study I – IV were elite male (I – III) and female (III – IV) cross-country skiers. In all studies, the relationship between test variables (general and ski-specific) and competitive performances (i.e. the results from competitions or the overall ski-ranking points of the International Ski Federation (FIS) for sprint (FISsprint) and distance (FISdist) races) were analysed. Test variables reflecting the subject’s general strength, upper-body and whole-body oxygen uptake, oxygen uptake and work intensity at the lactate threshold, mean upper-body power, lean mass, and maximal double-poling speed were investigated. Results The ability to maintain a high work rate without accumulating lactate is an indicator of distance performance, independent of sex (I, IV). Independent of sex, high oxygen uptake in whole-body and upper-body exercise was important for both sprint (II, IV) and distance (I, IV) performance. The maximal double-poling speed and 60-s double-poling mean power output were indicators of sprint (IV) and distance performance (I), respectively. Lean mass was correlated with distance performance for women (III), whereas correlations were found between lean mass and sprint performance among both male and female skiers (III). Moreover, no correlations between distance performance and test variables were derived from tests of knee-extension peak torque, vertical jumps, or double poling on a ski-ergometer with 20-s and 360-s durations (I), whereas gross efficiency while treadmill roller skiing showed no correlation with either distance or sprint performance in cross-country skiing (IV). Conclusion The results in this thesis show that, depending on discipline and sex, maximal and peak oxygen uptake, work intensity at the lactate threshold, lean mass, double-poling mean power output, and double-poling maximal speed are all externally valid physiological test variables for evaluation of performance capability among elite cross-country skiers; however, to optimally indicate performance capability different test-variable expressions should be used; in general, the absolute expression appears to be a better indicator of competitive sprint performance whereas the influence of body mass should be considered when evaluating competitive distance performance capability of elite cross-country skiers.

Optimal V. O2max-to-mass ratio for predicting 15 km performance among elite male cross-country skiers

The aim of this study was 1) to validate the 0.5 body-mass exponent for maximal oxygen uptake (V. O2max) as the optimal predictor of performance in a 15 km classical-technique skiing competition among elite male cross-country skiers and 2) to evaluate the influence of distance covered on the body-mass exponent for V. O2max among elite male skiers. Twenty-four elite male skiers (age: 21.4±3.3 years [mean ± standard deviation]) completed an incremental treadmill roller-skiing test to determine their V. O2max. Performance data were collected from a 15 km classicaltechnique cross-country skiing competition performed on a 5 km course. Power-function modeling (ie, an allometric scaling approach) was used to establish the optimal body-mass exponent for V . O2max to predict the skiing performance. The optimal power-function models were found to be race speed = 8.83⋅(V . O2max m-0.53) 0.66 and lap speed = 5.89⋅(V . O2max m-(0.49+0.018lap)) 0.43e0.010age, which explained 69% and 81% of the variance in skiing speed, respectively. All the variables contributed to the models. Based on the validation results, it may be recommended that V. O2max divided by the square root of body mass (mL⋅min−1 ⋅kg−0.5) should be used when elite male skiers’ performance capability in 15 km classical-technique races is evaluated. Moreover, the body-mass exponent for V . O2max was demonstrated to be influenced by the distance covered, indicating that heavier skiers have a more pronounced positive pacing profile (ie, race speed gradually decreasing throughout the race) compared to that of lighter skiers.

Study protocol of European Fans in Training (EuroFIT) : a four-country randomised controlled trial of a lifestyle program for men delivered in elite football clubs

Funding The EuroFIT study is funded by the European Union’s Seventh Framework Program for research technological development and demonstration under Grant Agreement no: 602170. The Health Services Research Unit, University of Aberdeen, is core funded by the Chief Scientist Office of the Scottish Government Health Directorates.

Running economy and blood lactate accumulation in elite football players with high and low maximal aerobic power

The purpose was to determine running economy and lactate threshold among a selection of male elite football players with high and low aerobic power. Forty male elite football players from the highest Swedish division (“Allsvenskan”) participated in the study. In a test of running economy (RE) and blood lactate accumulation the participants ran four minutes each at 10, 12, 14, and 16 km•h-1 at horizontal level with one minute rest in between each four minutes interval. After the last sub-maximal speed level the participants got two minutes of rest before test of maximal oxygen uptake (VO2max). Players that had a maximal oxygen uptake lower than the average for the total population of 57.0 mL O2•kg-1•minute-1 were assigned to the low aerobic power group (LAP) (n=17). The players that had a VO2max equal to or higher than 57.0 mL O2•kg-1•minute-1 were selected for the high aerobic power group (HAP) (n=23). The VO2max was significantly different between the HAP and LAP group. The average RE, measured as oxygen uptake at 12, 14 and 16km•h-1 was significantly lower but the blood lactate concentration was significantly higher at 14 and 16 km•h-1 for theLAP group compared with the HAP group.