Cognitive behavioural components in physiotherapy management of chronic whiplash associated disorders (WAD)--a randomised group study.

Different types of integrated management programmes have lately been introduced in the treatment of Whiplash Associated Disorders (WAD). In this study regular primary care physiotherapy and physiotherapy management with integrated components of cognitive-behavioural origin was compared in an experimental group study. The predictive value of self-efficacy was also addressed. In all thirty-three patients with chronic WAD were included in the trial. Results revealed no significant differences between groups in self-ratings of disability or pain intensity. However, among the self-reported benefits of treatment, patients in the experimental group reported significantly less pain than did the comparison group. At three months follow-up the experimental group also reported better performance of daily activities. Between group differences in the coping repertoire were found at pre-, post-and three-month follow-up. Generally, patients with high self-efficacy reported less use of 'maladaptive' and passive coping style than less self-efficient subjects at all times. In conclusion cognitive behavioural components can be useful in physiotherapy treatment for patients with chronic WAD, but their contributions are not yet fully understood. Self-efficacy is related to patients' use of different coping styles. Positive long-term outcomes in WAD-patients could therefore be improved by boosting self-efficacy and by teaching patients to use active, adaptive coping strategies.

Treating youth in pain: Comparing tailored behavioural medicine treatment provided by physical therapists in primary care with physical exercises.

OBJECTIVES: To study the efficacy of tailored behavioural medicine treatment within a physical therapy framework. METHODS: The study was a randomized controlled study (RCT): tailored behavioural medicine treatment (EXT) delivered by physical therapists (PTs) was compared with exercise-based treatment (CT). Thirty-two adolescents (mean age 14.3 years) with persistent pain participated. Data on pain-related disability and school attendance (primary outcomes), pain intensity, catastrophizing, fear of movement and self-efficacy were collected. RESULTS: The pain-related disability measured by the Functional Disability Inventory (FDI) resulted in mean score change of EXT = -18 and CT = -11, respectively. A significant change within both groups was found (EXT p = 0.003, CT p = 0.001), and a large effect size for FDI between the conditions was demonstrated (AUC of 0.77). For school attendance post-treatment, no difference was found between conditions. For secondary outcomes, a significant improvement in pain intensity and pain catastrophizing was found for the EXT and self-efficacy for the CT groups but no statistically significant difference between the two conditions was detected. Caution should be given to the small sample size, as it may affect the interpretation and generalizability of the results. CONCLUSION: In this study, differences between tailored behavioural medicine treatment delivered by PTs and exercise-based treatment could not be demonstrated, although the effect size was large. Patients who received either treatment demonstrated significant changes over time in pain-related disability. The low number of participants and suboptimal tailoring of the psychological components may partly explain the failure to demonstrate differences between groups, and future studies are warranted.

Beyond 18F-FDG: Characterization of PET/CT and PET/MR Scanners for a Comprehensive Set of Positron Emitters of Growing Application--18F, 11C, 89Zr, 124I, 68Ga, and 90Y.

UNLABELLED: This study aimed to investigate image quality for a comprehensive set of isotopes ((18)F, (11)C, (89)Zr, (124)I, (68)Ga, and (90)Y) on 2 clinical scanners: a PET/CT scanner and a PET/MR scanner. METHODS: Image quality and spatial resolution were tested according to NU 2-2007 of the National Electrical Manufacturers Association. An image-quality phantom was used to measure contrast recovery, residual bias in a cold area, and background variability. Reconstruction methods available on the 2 scanners were compared, including point-spread-function correction for both scanners and time of flight for the PET/CT scanner. Spatial resolution was measured using point sources and filtered backprojection reconstruction. RESULTS: With the exception of (90)Y, small differences were seen in the hot-sphere contrast recovery of the different isotopes. Cold-sphere contrast recovery was similar across isotopes for all reconstructions, with an improvement seen with time of flight on the PET/CT scanner. The lower-statistic (90)Y scans yielded substantially lower contrast recovery than the other isotopes. When isotopes were compared, there was no difference in measured spatial resolution except for PET/MR axial spatial resolution, which was significantly higher for (124)I and (68)Ga. CONCLUSION: Overall, both scanners produced good images with (18)F, (11)C, (89)Zr, (124)I, (68)Ga, and (90)Y.

A comparison of 50, 100 and 200 mg of intra-articular pethidine during knee joint surgery, a controlled study with evidence for local demethylation to norpethidine.

Pethidine (meperidine) is a compound with both local anaesthetic and opioid agonist properties. We have in a recent study demonstrated that pethidine could be an interesting alternative to prilocaine in arthroscopy with local anaesthetic technique. Therefore, we investigated, in a controlled randomized double-blind study, the effect of three doses of pethidine compared with a standard local anaesthetic, in patients subjected to arthroscopic knee joint surgery. Ten patients in each group received 50 mg (P50), 100 mg (P100), 200 mg (P200) of pethidine or prilocaine (5 mg/ml) + adrenaline (4 mg/ml) (PC), injected intra-articularly (i.a.) before surgery. We measured pain intensity and discomfort during arthroscopy and pain intensity at rest and at movement, nausea and tiredness for 3 days post-operatively at regular intervals using the VAS-technique. We also measured the concentration of pethidine and its demethylated metabolite, norpethidine, in plasma by collecting blood samples at 20, 40, 60, 80, 140 and 200 min following injection, and in synovial fluid which was collected through the arthroscope at the start and the end of the surgery. It was found that significantly more patients in the P50 group (n = 6) needed general anaesthesia due to intense pain than those in the P100 group (n = 1), P200 group (n = 0) or the PC group (n = 1). The PC group required significantly more analgesics and had a significantly higher calculated total sum of pain scores at movement post-operatively, than the other three groups. The P200 group more often reported tiredness post-operatively than the other three groups. We conclude that 100 or 200 mg pethidine i.a. produces satisfactory anaesthesia for surgery. There was a rapid transfer of pethidine from synovial fluid to plasma, resulting in plasma levels earlier reported to produce centrally mediated effects, such as analgesia and tiredness. We found much higher concentrations of norpethidine in the synovial fluid than in plasma, suggesting a local demethylation in the knee joint tissues. This site of drug oxidation has not earlier been demonstrated neither in vitro nor in vivo. The results suggest that pethidine given i.a. in the dose range of 50 to 200 mg results in analgesia due to both peripheral and central mechanisms. The significant systemic uptake of pethidine can cause unwanted side-effects.

Allergen induced cytokine profiles in type I allergic individuals before and after immunotherapy.

Allergen immunotherapy (IT) involves subcutaneous injections of increasing doses of specific allergen over a period of time. It is recognised as highly effective in the treatment of patients with allergic rhinitis. However, the specific immunological mechanisms by which IT achieves its effect have not been fully elucidated. Recent studies, have shown that the clinical effects following IT of allergic individuals is concomitant with a reduced production of IL-4 by allergen specific CD4+ T-cells. The aim of the present study was to gain better knowledge about the immunological mechanisms by which IT exerts its beneficial effects. For this purpose, peripheral blood mononuclear cells (PBMC) from ten individuals receiving birch allergen or placebo in an IT-study performed in a double-blind manner, were analysed for IL-4, IFN-gamma, IL-5 and IL-10 mRNA expression at the onset of the study and during the pollen season, during treatment. Both spontaneous and in vitro allergen-induced cytokine mRNA expression was analysed using reverse transcriptase-polymerase chain reaction (RT-PCR). Spontaneous expression of IL-4 mRNA could be detected in most of the allergic patients, but not in healthy donors. The IT-treated patients showed a decrease in the spontaneous expression of IL-4 mRNA during the pollen season as compared to at the onset of the study, while in patients receiving placebo the IL-4 mRNA expression increased or remained unchanged. Similar results were obtained after in vitro stimulation with allergen. This was in contrast to the results for IFN-gamma, which was readily detected in both patient groups with no significant differences between the groups at either timepoint. IL-5 was shown to be increased during the pollen season in both groups and thereby presumably not affected by allergen IT. Taken together, these observations suggest that the cytokine profiles in circulating T lymphocytes change as a consequence of allergen IT.

An integrated physiotherapy/cognitive-behavioural approach to the analysis and treatment of chronic whiplash associated disorders, WAD.

PURPOSE: The aim of this paper was to describe a model for an integrated physiotherapy/cognitive-behavioural approach in the analysis and treatment of chronic WAD patients, as well as to evaluate the effectiveness of this approach in three experimental single case studies. METHOD: Three patients with a diagnosis of chronic WAD were included in the study. Psychological and physical functional analyses were used to describe the problem areas and as a basis for the management of WAD. A programme including learning of basic and applied skills, generalization, and maintenance was carried through. RESULTS AND CONCLUSION: The results showed that functional behavioural analyses can be useful in physiotherapy for structured patient assessment and in planning of treatment. It was also shown that physiotherapy integrated with cognitive behavioural components decreased the patients' pain intensity in problematic daily activities.

Long-term functional and psychological problems in whiplash associated disorders.

In recent years, Whiplash Associated Disorders (WAD) have been recognized as an increasing problem and up to 35% of patients have been reported to suffer from persisting symptoms. The aim of this study was to describe the consequences of pain and impairment of movement for everyday activities and dysfunction, in a sample of 104 chronic WAD patients. It was hypothesized that predictors such as initial grade of injury, self-efficacy and optimism, as well as mediating coping strategies, would influence the patients' quality of life in terms of dysfunction, disability, anxiety, depression and pain intensity. The results showed that chronic WAD patients differ from other groups in quality-of-life related indicators. Psychosocial problems were more pronounced than physical, while there were no gender differences. There was some evidence that use of specific coping strategies is a significant predictor of psychological well-being.

Self-reported health and physical activity among community mental healthcare users.

The aim of the study was to survey the self-reported health and physical activity in a sample of community mental healthcare users in a city of Sweden. The study was conducted through a cross-sectional design with participants requested to fill out a self-report questionnaire. Participants (n = 103) were persons with psychiatric disabilities living in residential psychiatric settings and/or participating in daily activities provided by community mental healthcare services. The results showed that the group is affected with serious risk factors, such as high body mass index, low rated extent and frequency of physical activity and low self-estimated general state of health. Even though some difficulties associated with the answering process of this questionnaire emerged, these self-reported results clearly confirm the fact that persons with psychiatric disabilities constitute a vulnerable group in need for health-promoting caring activities and interventions.

Acute whiplash-associated disorders (WAD): the effects of early mobilization and prognostic factors in long-term symptomatology.

OBJECTIVE: To compare two different home exercise programmes for patients with acute whiplash-associated disorders (WAD). A further aim was to describe the initial prognostic variables related to self-reported pain at six months follow-up. DESIGN: A randomized treatment study with a follow-up period of six months. SETTINGS: The study was undertaken in an orthopaedic clinic at a university hospital. SUBJECTS: A total of 59 symptomatic (neck pain, stiffness, etc.) patients with acute whiplash injury. INTERVENTIONS: Patients were randomized to a regular treatment group (RT group) and an additional-exercise treatment group (AT group). MAIN OUTCOME MEASURES: Pain Disability Index (PDI), Self-Efficacy Scale (SES), Coping Strategies Questionnaire (CSQ), neck range of motion (ROM), head posture, kinaesthetic sensibility, visual analogue scale (VAS). RESULTS: Patients given an additional exercise did not improve more than patients with regular treatment. Only one CSQ item, 'Ability to decrease pain', showed a significant difference between the groups in its pattern of change over time: the AT group had a significant increase between three and six months whilst values in the RT group decreased. Nonsymptomatic patients at six months follow-up were characterized by initially better self-efficacy, lower disability and significantly different patterns in the use of 'behavioural coping strategies' when compared with symptomatic patients. The nonsymptomatic patients also reported more frequent training than symptomatic patients, i.e. they complied better with the treatment regime. CONCLUSION: This home exercise programme, including training of neck and shoulder ROM, relaxation and general advice seems to be sufficient treatment for acute WAD patients when used on a daily basis. Additionally, patients reporting low self-efficacy and high disability levels may profit from more attention initially, as these psychological factors are significant predictors of pain at long-term follow-up.

"I could not lift my arm holding the fork...". Living with chronic fatigue syndrome.

OBJECTIVES: To explore and describe symptoms and their consequences for patients suffering from chronic fatigue syndrome (CFS). DESIGN: Qualitative data from a group interview, written answers to a questionnaire and a follow-up meeting analysed in accordance with Giorgi's phenomenological approach. SUBJECTS: Purposeful sample of 10 women and 2 men of various ages recruited from the local self-help patient organisation. MAIN OUTCOME MEASURES: Descriptions reflecting the nature, extent and consequences of symptoms regarded as the most substantial by the informants across the group. RESULTS: Extreme exhaustion exceeding the nature of everyday weariness was reported as the worst symptom. The informants perceived reduced muscular strength, continuous weakness and recurrent pain, problems related to memory and concentration, sleep disturbances and excessive sensitivity towards smell, light and sound. Learning abilities had deteriorated, and housework, conversation, reading and watching TV were characterised as exhausting, leading to an unpredictability of everyday life-disturbing social relations. CONCLUSION: The extent and nature of symptoms suggest that CSF is an essentially different and far more serious condition than the strains of everyday life. Our findings suggest immunological processes affecting the neuromuscular and central neural system comparable to the effects of cytostatic medication.

Is intra-articular pethidine an alternative to local anaesthetics in arthroscopy? A double-blind study comparing prilocaine with pethidine.

We investigated the per- and postoperative pain-reducing effect of pethidine given intra-articularly (i. art.). Thirty patients subjected to knee joint arthroscopy, diagnostic and surgical procedures, were randomly assigned to one of three groups. Group A consisted of ten patients who received 250 mg prilocaine + 200 micrograms adrenaline (i. art.) in a volume of 50 ml, group B of ten patients who received 200 mg pethidine (i. art.) in 50 ml saline, and group C of ten patients who received 200 mg pethidine + 200 micrograms adrenaline (i. art.) in 50 ml saline. During arthroscopy the patients reported on pain intensity and discomfort using visual analogue scales. Ratings were low and did not differ significantly between the three groups. Two of three patients in each group requested additional analgesics or sedatives due to pain and discomfort, but again with no difference between the three groups. Postoperatively all patients rated their pain intensity at rest and during movement (at 0, 1, 2, 3, 4, 5, 6, 12 and 24 h). The patients receiving pethidine (group B) reported significantly less pain at rest and movement than group A patients, in general at 1-4 h postoperatively. A significant difference was detected between groups B and C at 4 h postoperatively. Calculating the total sum of pain scores, patients receiving pethidine (group B) reported significantly less pain both at rest and during movement than those receiving prilocaine (group A). Furthermore, patients in group B used significantly less analgesics than those in group A. Adrenaline did not potentiate the effect of pethidine.(ABSTRACT TRUNCATED AT 250 WORDS)

[Symptoms in women with Sjogren's syndrome]. / Symptomopplevelser hos kvinner med Sjögrens syndrom.

More knowledge about symptom experience is needed for diagnosing Sjögren's disease at an early stage of disease development. We have performed a qualitative study based on group interview with eight women with Sjögren's disease. The women presented with several different symptoms. They all described weariness, fatigue, sicca symptoms, various pains, hypersensitivity and organ manifestations in the same manner. Some of the symptoms had a dramatic impact on their life activities. The study revealed new descriptions of previously known symptoms and descriptions of previously unfamiliar symptoms. The results of the study may supplement the existing criteria of Sjögren's disease and provide new hypotheses about pathogenetic mechanisms related to chest pain, abdominal pain and facial pain in patients with Sjögren's disease.

Analgesia following arthroscopy--a comparison of intra-articular morphine, pethidine and fentanyl.

It has recently been reported that morphine given in low doses intra-articularly can produce significant analgesia in patients undergoing arthroscopic knee joint surgery. Data are lacking on the effect of other opioids using a local approach for drug delivery. We studied the analgesic effect of intra-articular opioids in 70 patients, divided into 7 groups, subjected to arthroscopic knee surgery in general anesthesia. The dimension of the study was based on a power of 0.8 to detect a 25% difference in pain intensity between those receiving opioids locally versus systemically (alpha = 0.05 and beta = 0.20). Following surgery, but before terminating anesthesia, the patients received one of the following combinations: 1 mg morphine intra-articularly (i.art.) + saline intramuscularly (i.m.), 10 mg pethidine i.art + saline i.m., or 10 micrograms fentanyl i.art + saline i.m. In three additional groups the three opioids were given i.m. and saline given i.art. An additional control group received saline i.art. + i.m. We did not find any significant difference between the groups considering postoperative pain intensity, need for analgesics or considering time to standing/walking or to discharge, analysing each opioid independently. There was, however, a tendency for pethidine i.art. to produce the lowest pain scores both at rest and during movement (P = 0.06). If analysing the results with regards to if opioids were given intra-articularly or systemically, not considering the type of opioid given, we did however, find a significantly lower total sum of pain scores at movement following local administration (P < 0.05). No specific side-effects were detected. We conclude that pethidine given intra-articularly merits further investigation with respect to postoperative analgesia following the activation of peripheral opioid mechanisms.

Influence of atopic heredity on IL-4-, IL-12- and IFN-gamma-producing cells in in vitro activated cord blood mononuclear cells.

Several reports have claimed that there is a greater risk for a child with an atopic mother to develop allergy as compared to a child with an atopic father. This suggests that the fetal environment during pregnancy might be of importance for the development of atopic disease. Both proliferative and cytokine responses have been detected in cord blood mononuclear cells (CBMC) after stimulation with allergens, suggesting allergen priming already in utero. The aim of this study was to investigate whether the atopic status of the mother influences cytokine production by CBMC. We compared interleukin (IL)-4, IL-12 and interferon (IFN)-gamma-producing CBMC from children with double atopic heredity (dh), maternal atopic heredity only (mh) or no atopic heredity (nh). CBMC were stimulated in vitro with allergens (birch, ovalbumin and cat), phytohaemagglutinin (PHA) or purified protein derivative (PPD) and cytokine-producing cells were measured by the enzyme-linked immunospot assay. In response to PHA, the frequency of IL-4-producing cells, as well as the ratio of IL-4/IFN-gamma-producing cells, were significantly higher in the dh group compared to the nh group. High numbers of IL-12-producing cells in response to allergens were detected, significantly highest in the nh group, followed by the dh and mh groups. Our results suggest that there is a stronger Th2 bias after in vitro stimulation of CBMC from children with atopic heredity, as reflected by higher IL-4/IFN-gamma ratios in response to PHA, and lower numbers of IL-12-producing cells after allergen stimulation. Whether these differences influence later allergy development will be evaluated when the atopic status of the children is assessed at 2 years of age.

Increased frequencies of allergen-induced interleukin-13-producing cells in atopic individuals during the pollen season.

We have reported previously that allergen-specific serum IgE levels were correlated with allergen-induced interleukin (IL)-4 in type I allergic individuals. Here, we wanted to investigate whether IL-13, another switch factor for IgE, was induced by allergen in vitro and if so, whether this was correlated with the elevated serum IgE-levels seen in atopic individuals, and whether the cytokine profile changed during pollen season. Peripheral blood mononuclear cells from 14 atopic and 14 healthy individuals collected out of the pollen season were incubated in vitro with allergens (birch or timothy) and the number of IL-4, IL-13, IL-10 and IFN-gamma producing cells was determined by ELISPOT. In response to the specific allergen, IL-13-producing cells were seen in allergic but not in healthy individuals. The number of IL-13-producing cells was significantly correlated with the allergen-specific serum IgE levels. When the allergic individuals were tested during the pollen season, the number of allergen-specific IL-4- and IL-13-producing cells, as well as serum levels of specific IgE, increased. The IL-13 increase seen in ELISPOT was confirmed by a RT-PCR assay. No seasonal changes were seen in response to purified protein derivative (PPD) or the mitogen PHA. During the pollen season, the IL-4 and IL-13 responses were highly correlated. Taken together, our results support the roles of both IL-13 and IL-4 in the regulation of allergen-specific IgE levels in atopic individuals.

Abnormal T cell receptor V gene usage in myasthenia gravis: prevalence and characterization of expanded T cell populations.

The usage of T cell receptor (TCR) Valpha/Vbeta chains on cells from 38 patients with myasthenia gravis (MG) was determined by flow cytometry. There was a decreased number of cells expressing Vbeta2 in CD8+ and Vbeta3 in CD4+ cells in patients compared with healthy individuals. Abnormal expansions of T cells using particular TCR Valpha/Vbeta gene products were found in 18/38 patients. A significantly higher usage of Vbeta13 was observed but there was no restriction with regard to other TCR Valpha/Vbeta. Expanded cells belonging to both CD4+ and CD8+ were present in MG patients while restricted to the CD8+ population in healthy individuals. To elucidate the role of the expanded populations, we studied characteristics of the expanded and non-expanded T cells from MG patients who had persistent T cell expansions over more than 2 years. The cells were analysed with regard to phenotype, cytokine secretion, cytokine mRNA expression and reactivity with the autoantigen, the acetylcholine receptor. The characteristics of the expanded populations in MG clearly differed from those found in healthy individuals. More cells in the CD4+ expanded populations expressed HLA-DR and there was also a tendency for higher expression of CD25, CD28 and CD57. The number of cells spontaneously secreting cytokines was higher in the expanded populations. A dominant Th1-type cytokine secretion and mRNA expression was noted. Autoantigen-reactive CD4+ T cells were largely restricted to the expanded populations.

Specific immunotherapy prevents increased levels of allergen-specific IL-4- and IL-13-producing cells during pollen season.

BACKGROUND: Specific allergen immunotherapy (SIT) is effective for treatment of IgE-mediated diseases: however, the mechanisms of action still remain unclear. Earlier, we showed that IL-4 and IL-13 are produced in response to specific allergens. The aim of this study was to investigate whether these cytokine responses were affected by allergen SIT, and, furthermore, to evaluate the effect of SIT on allergen-specific IgE and IgG4 levels. METHODS: Blood samples from pollen-sensitized individuals were collected before the pollen season (before treatment) and during the pollen season (after SIT or placebo treatment). Peripheral blood mononuclear cells were activated in vitro with allergens and the numbers of IL-4-, IL-13-, IL-10-, and IFN-gamma-producing cells were determined by ELISPOT. Serum levels of allergen-specific IgE and IgG4 were measured by RAST and ELISA, respectively. RESULTS: The numbers of IL-4- and IL-13-producing cells were shown to be increased in the placebo group during the pollen season, an increment which was absent in patients receiving allergen SIT. We found an increase in allergen-specific IgG4 in the SIT-treated individuals, but not in the placebo group. Both groups displayed elevated specific IgE levels during the pollen season. CONCLUSIONS: Taken together, our data show a downregulation of IL-4- and IL-13-producing cells in peripheral blood after SIT, suggesting induction of nonresponsiveness/tolerance or a redistribution of these cells. Furthermore, we demonstrate that SIT acts on antibody production by increasing the specific IgG4 levels.