Women at work despite ill health: diagnoses and pain before and after personnel support. A prospective study of hospital cleaners/home-help personnel with comparison groups.

The present study sought to elicit the diagnoses behind the pain conditions causing complaints by female hospital cleaners and home-help personnel who were working despite their symptoms. We also wished to describe the prevalence of musculoskeletal diagnoses and the intensity, frequency and location of pain, and changes in the clinical picture and pain after personnel supporting interventions. A prospective study was carried out with intervention groups and non-randomized comparison groups. The hospital cleaners intervention programme comprised occupational organizational measures, competence development, physical and psychosocial working environmental measures and individual and rehabilitation measures on both an individual and a group basis. The home-help programme comprised a 2-week stay at an orthopaedic rehabilitation unit, training of supervisors, comrade massage, purchase of training equipment and stress management. Myalgia/ tendinitis occurred in 61% of shoulder girdle elevators, 18% of rotator cuffs, 16% of dorsal neck muscles and 29% of hip muscles. There was musculoskeletal pain in the lower back in 28% of cases. Referred pain from a musculoskeletal focus occurred in about one-sixth to one-third of individuals with the diagnosis in question. Neurogenic pain occurred in 6% of cases. No fibromyalgia syndrome was found. One-third of individuals felt pain all the time or almost all the time. The mean rated perceived "worst pain" was 70 mm on a visual analogue scale of 1-100 mm. Comparisons between intervention and reference groups indicated that some improvement in the clinical picture can be attained using this kind of general support programme for employees.

Vocational rehabilitation--early versus delayed. The effect of early vocational rehabilitation compared to delayed vocational rehabilitation among employed and unemployed, long-term sick-listed people.

The aim of the present study was to examine whether the wait before vocational rehabilitation affected the outcome for employed and unemployed, long-term sick-listed people. The study is based on sick-leave cases 90 days or longer, which started during 1992-1994 in a rural area in Sweden. The study included all sick-leavers with non-malignant musculoskeletal diagnoses from the neck, shoulder and back regions and who had undergone vocational rehabilitation. Of these, 391 were employed and 78 unemployed. Our hypothesis was that those who undergo early vocational rehabilitation, irrespective of employment status, often get well sooner, have fewer sick days and lower benefit levels after vocational rehabilitation than those who have to wait a long time for their rehabilitation. Our hypothesis was supported only regarding the employed who mainly reported well at 6 and 12 months after vocational rehabilitation. In the longer term (24 months) the effect was however no longer evident. Earlier studies indicate that more factors than an early start to rehabilitation are important for a successful outcome. A more important factor is probably that the right measures have been initiated at the right time, that the measures are of high quality and that the sick-leaver is mentally prepared for the measure. Although early vocational rehabilitation did not prove to be a determining factor for a successful outcome there is still reason to emphasize early involvement in the case to guarantee rehabilitation of high quality.

Rehabilitative, psychiatric, functional and aesthetic problems in patients treated for burn injuries--a preliminary follow-up study.

Patients consecutively treated for burn injuries for four or more days during 1994 were examined one year after admission by a plastic surgeon, a specialist in rehabilitation medicine and a psychiatrist. Of thirty-nine such patients treated, two were dead, 11 did not present and six thought they had no remaining problems. Aesthetic and functional problems were present in 16 patients, in 11 reconstructive surgery given in one or more sessions was judged to have improved the condition. Of eighteen patients referred to a rehabilitation medicine specialist, 14 were assessed. Nine of these had functional impairments in the burn-injured body regions. A majority had functional impairments, persistent decrease in range of upper extremity motion, reduced muscle force, altered sensibility and itch. One patient suffered from pain. Three patients had occupational handicaps. Work disability occurred in two patients and further two were in need of vocational counselling due to the burn injury. In a subgroup of 11 patients four fulfilled criteria for one or more personality disorders, and two of these also suffered from major depression. Quality of life assessed with the SF-36 was lower than in a normal population. Some of the patients had psychiatric disease and personality disorders. Although rehabilitation started early in the acute phase of treatment, rehabilitation medicine function-increasing measures were needed in several cases. Individual rehabilitation programmes based on the patient's particular features and needs are recommended. The findings support the idea of a multidisciplinary approach for patients with burn injury and indicate that a subgroup of burn injury patients have functional impairments and/or disabilities which can probably be improved with reconstructive surgery and rehabilitation.

Sensory dysfunction in fibromyalgia patients with implications for pathogenic mechanisms.

This study, addressing etiologic and pathogenic aspects of fibromyalgia (FM), aimed at examining whether sensory abnormalities in FM patients are generalized or confined to areas with spontaneous pain. Ten female FM patients and 10 healthy, age-matched females participated. The patients were asked to rate the intensity of ongoing pain using a visual analogue scale (VAS) at the site of maximal pain, the homologous contralateral site and two homologous sites with no or minimal pain. Quantitative sensory testing was performed for assessment of perception thresholds in these four sites. Von Frey filaments were used to test low-threshold mechanoreceptive function. Pressure pain sensitivity was assessed with a pressure algometer and thermal sensitivity with a Thermotest. In addition the stimulus-response curve of pain intensity as a function of graded nociceptive heat stimulation was studied at the site of maximal pain and at the homologous contralateral site. FM patients had increased sensitivity to non-painful warmth (P < 0.01) over painful sites and a tendency to increased sensitivity to non-painful cold (P < 0.06) at all sites compared to controls, but there was no difference between groups regarding tactile perception thresholds. Compared to controls, patients demonstrated increased sensitivity to pressure pain (P < 0.001), cold pain (P < 0.001) and heat pain (P < 0.02) over all tested sites. The stimulus-response curve was parallely shifted to the left of the curve obtained from controls (P < 0.003). Intragroup comparisons showed that patients had increased sensitivity to pressure pain (P < 0.01) and light touch (P < 0.05) in the site of maximal pain compared to the homologous contralateral site. These findings could be explained in terms of sensitization of primary afferent pathways or as a dysfunction of endogenous systems modulating afferent activity. However, the generalized increase in sensitivity found in FM patients was unrelated to spontaneous pain and thus most likely due to a central nervous system (CNS) dysfunction. The additional hyperphenomena related to spontaneous pain are probably dependent on disinhibition/facilitation of nociceptive afferent input from normal (or ischemic) muscles.

The human platelet as a reproducible and sensitive cell for the detection and assay of platelet-activating factor.

A new procedure for the preparation of human platelets consistently sensitive to platelet-activating factor (PAF) in the low nanomolar range has been developed. Key to the success of this approach was the addition of adenosine during the isolation phase, providing an excellent recovery of stable cells, and the inclusion of ADP in the aggregation assay, providing increased sensitivity to PAF. Examination of the binding profile of tritium-labeled PAF to these platelets in the presence or absence of ADP revealed significant difference in the Kd values but not in the number of specific binding sites. Other reagents having an influence on the reactivity and stability of the human platelets, as regards its interaction with PAF, are described.

Biochemical characterization of density-separated human erythrocytes.

A simple, reproducible method for the separation of human erythrocytes, described recently (Murphy, J. R. (1973) J. Lab. Clin. Med. 82, 334-341) has been utilized for the purpose of obtaining a wide range of biochemical data on these cells. Using phthalate ester density centrifugation of the fractions obtained by Murphy's method, we established that the cells were separated exclusively on the basis of their densities. Data on a wide range of biochemical and hematological parameters, when compared with previously reported density separation procedures showed that this simple technique can be used to fractionate the cells according to their densities (age) in their own plasma. Cells of increasing density consistently and reproducibly exhibited an increase in hemoglobin concentration, a moderate elevation in Na+ and a decrease in the following: K+, acetylcholinesterase, sialic acid, membrane protein, 2,3-diphosphoglycerate, ATP, cholesterol, phospholipid, mean corpuscular volume and critical hemolytic volume, However, no change in mean corpuscular hemoglobin was evident. The observed differences were not artifacts of the centrifugation process. This was determined in recentrifuged top fractions from which new top and bottom cells were obtained. The latter cells resembled the top fraction from which they were obtained, rather than the original bottom fraction. Whereas the parameters mentioned above exhibited consistency and reproducibility, such was not the case with the ATPase values. Depending on the cell density group examined and/or buffer as well as other conditions, significant variability in the activity levels of the ouabain sensitive, as well as the Ca2+ -stimulated ATPase, was observed. Use of these enzyme activities as indicators of cell age must be viewed with caution.