Intensive training, physiotherapy, or manipulation for patients with chronic neck pain. A prospective, single-blinded, randomized clinical trial.

STUDY DESIGN: A randomized, prospective clinical study was conducted that included 119 patients with chronic neck pain of greater than 3 months' duration. OBJECTIVES: To compare the relative effectiveness of intensive training of the cervical musculature, a physiotherapy treatment regimen, and chiropractic treatment on this patient group. SUMMARY OF BACKGROUND DATA: There are only a few studies involving chronic neck pain patients representative of those seeking care in primary health care centers. Mobilization techniques and intensive training have been shown to be useful, but cervical manipulation has not been assessed. Clinical results involving these commonly used therapies have not been compared. METHODS: A total of 167 consecutive patients were screened. One hundred nineteen patients were admitted to the study and were randomized according to Taves' minimization principles. Primary outcome measures included self-reported pain, disability, medication use, patients' perceived effect, and physician's global assessment. Patients were assessed at enrollment and at completion of the study. Postal questionnaires were used to carry out 4- and 12-month follow-up assessments. Secondary outcome measures included active range of motion of the cervical spine as well as strength and endurance measurements of the cervical musculature. These measurements were carried out at enrollment and completion of the study. RESULTS: A total of 88% of the patients completed the study. Of these, 97% completed the 4-month questionnaire and 93% the 12-month questionnaire. Patients from all three groups demonstrated significant improvements regarding self-reported pain and disability on completion of the study. Improvements were maintained throughout the follow-up period. Medication use was also significantly reduced in all groups. There was, however, no significant difference between groups at any assessment period. Physician's and patients' assessments were also positive, and again group scores were essentially equal. Patients who underwent intensive training demonstrated significantly greater endurance levels at the completion of treatment. CONCLUSIONS: There was no clinical difference between the three treatments. All three treatment interventions demonstrated meaningful improvement in all primary effect parameters. Improvements were maintained at 4- and 12-month follow-up. However, whether this was a result of the treatments or simply a result of time is unknown. Future studies will be necessary to delineate ideal treatment strategies.

Minnesota Multiphasic Personality Inventory profiles in persons with or without low back pain. A 20-year follow-up study.

STUDY DESIGN: A general health survey including a cross-sectional study of 404 men and women aged 50 years who underwent follow-up evaluation at ages 60 and 70 years. OBJECTIVES: The participants completed the Minnesota Multiphasic Personality Inventory at age 50 and 60 years and were interviewed at age 60 and 70 years regarding low back pain experienced in the preceding 10 years. SUMMARY OF BACKGROUND DATA: Minnesota Multiphasic Personality Inventory data in low back pain patients are derived mainly from selected materials. This study presents data from a general population and sheds light on the controversy: "What comes first--Minnesota Multiphasic Personality Inventory changes or low back pain?". METHODS. Within the frame of a general health survey where the primary aim was to study cardiovascular risk factors, the participants completed a shortened Danish version of the Minnesota Multiphasic Personality Inventory at age 50 and 60 years; low back pain data were collected at interviews at age 60 and 70 years, and this study focused on the Hypochondriasis-Depression-Hysteria scales of the Minnesota Multiphasic Personality Inventory. RESULTS: Presence of low back pain from ages 50 to 60 and from ages 60 to 70 years was associated with elevated Hypochondriasis-Depression-Hysteria scales at age 50 and 60 years. Profiles showing the "conversion-V" configuration were present with a history of low back pain, at the 50-year and 60-year Minnesota Multiphasic Personality Inventory test. Minnesota Multiphasic Personality Inventory scores collected at age 50 years were not different between those who did report and those who did not report low back pain during the decade from 60 to 70 years, provided that they had not experienced low back pain during the period from age 50 to 60 years. CONCLUSIONS: Elevations of Minnesota Multiphasic Personality Inventory Hypochondriasis-Depression-Hysteria scales were shown in persons with a history of low pack pain. The results indicated that low back pain is preceded by elevated Minnesota Multiphasic Personality Inventory scales was not supported.

A model of regular geriatric follow-up by home visits to selected patients discharged from a geriatric ward: a randomized controlled trial.

The aim of this randomized controlled trial was to describe and evaluate a model of regular follow-up by home visits to selected elderly patients discharged from a geriatric ward. Ninety-seven patients were randomized to receive regular follow-up visits by a geriatric team at 1, 3, 8 and 16 weeks after discharge, and 96 patients to receive standard care. Based on the geriatric evaluation, medical and social adjustment was carried out, if indicated. Six months after discharge, significantly more patients in the intervention group were allocated to home help (p < 0.05), but only 42 (44%) were readmitted to a hospital, vs 62 (64%) in the control group (p < 0.005). Differences between the groups in mortality and nursing-home placement were not statistically significant. Regular follow-up home visits by a geriatric team after in-patient geriatric evaluation and management reduce the risk of hospital readmissions among highly selected frail geriatric patients.

[Follow-up home visits to elderly patients after hospitalization. A randomized controlled study]. / Opfølgende hjemmebesøg til aeldre efter hospitalsindlaeggelse. En randomiseret, kontrolleret undersøgelse.

The aim of this randomized, controlled study was to evaluate a model for follow-up of patients aged 75 or more after discharge from hospital. One hundred and sixty-three patients from the intervention group were visited in their homes by a district nurse on the day after discharge from hospital and two weeks later by their general practitioner. For 181 control patients, discharge took place according to the usual procedures. One year after discharge 25 patients from the control group had been admitted to nursing homes compared to ten from the intervention group (p < 0.05). At the same time the control patients stayed 2700 days in the institutions, the intervention patients 1950 days. It is proposed to introduce this simple and practicable follow-up routine when elderly people are discharged from hospital.

Intensive, dynamic back-muscle exercises, conventional physiotherapy, or placebo-control treatment of low-back pain. A randomized, observer-blind trial.

In a randomized, observer-blind trial, 150 men and women, aged 21-64 years, with chronic/subchronic low-back pain, followed one of these three treatment regimens: 1) intensive, dynamic back-muscle exercises; 2) conventional physiotherapy, including isometric exercises for the trunk and leg muscles; and 3) placebo-control treatment involving semihot packs and light traction. Eight treatment sessions were given during the course of 4 weeks, each session lasting 1 hour. The short-term effect was evaluated at the end of the treatment period and 1 month later, and the long-term effect at 6 and 12 months. The evaluations included recording of changes in pain level and assessment of overall treatment effect, which were indicated on visual interval scales. Subgroups of patients could be identified according to their treatment responses: physiotherapy was the superior treatment for the male participants, whereas the intensive back exercises appeared to be most efficient for the female participants. Patients with moderate or hard physical occupations tended toward a better response with physiotherapy, whereas intensive back exercises seemed most effective for those with sedentary/light job functions.

Geriatric follow-up by home visits after discharge from hospital: a randomized controlled trial.

The aim of this prospective, randomized and controlled trial was to carry out and evaluate a model for follow-up by home visits after discharge from hospital of persons aged 75 years or more. The trial was a feasibility study in which hospital staff, district nurses, and general practitioners already working within the hospital and the primary health sector participated, with changes in the usual organization. On the day after their discharge from hospital, 163 patients were visited in their homes by the district nurse. Two weeks later, they were evaluated at home by their general practitioner. For 181 control patients, discharge took place according to the usual procedures. Endpoints were evaluated one year after discharge. Significantly more patients from the control group had been admitted to nursing homes as compared with the trial group (25/10, p < 0.05); the control patients stayed 2700 days at institutions, the trial group 1950 days. It is proposed that this simple and practicable follow-up routine be introduced in connection with discharge of elderly persons from hospital.

[Experiences of a geriatric team attached to a hospital]. / Erfaringer fra et geriatrisk team knyttet til et sygehus.

The Geriatric Team in Glostrup Hospital was established on 1. Oct. 1990. The object of the team is to carry out relevant and rapid geriatric assessment by means of a multidisciplinary structure where hospitalized persons and persons living at home are concerned. During the first six months, 247 patients were referred to the team (83% from other hospital departments and 17% from general practitioners). Subsequently, 116 patients (47%) were referred to the subacute geriatric section and 28 (12%) to the other geriatric departments of the hospital. Out of the 41 patients who were assessed in their homes after referral by the general practitioner, treatment could be concluded in 22 (54%) without hospitalization. The close association with the other geriatric functions and the other departments of the hospital has proved decisive for the function of the team. The extroverted and rapid treatment has implied that the geriatric department has become much more significant in the hospital. As compared with the situation previously, many more geriatric problems could be relieved in the other departments. Parallel with consolidation of the internal function in the hospital, the aim of the team is further strengthening of cooperation with the partners in the primary community with the object of treatment the majority of elderly persons in their own homes.

[The subacute function in a geriatric department]. / Den subakutte funktion i en geriatrisk afdeling.

The Subacute Geriatric Department in Glostrup Hospital was established on 1 Oct. 1990 as the first in Denmark. Elderly patients with composite disease and who may be anticipated to be discharged after geriatric treatment for one to two weeks, are admitted after referral from the geriatric team. A total of 116 patients were admitted to the eight beds in the department during the period 1 Oct. 1990-31 Mar. 1991. The average period of hospitalization was 9.1 days. The majority of patients were referred from the two medical departments. 20% were admitted directly from the casualty or admission department while 10% were referred by their general practitioners. In this department, diagnostic activity corresponding to that offered in medical departments could be performed. Simultaneously, all of the patients were assessed by a physiotherapist on the day of admission. Ninety-seven patients (84%) were discharged to their homes. On follow-up investigation after three months, 72% were still in their own homes. By means of multi-disciplinary cooperation in the department, it has proved possible to combine intensive investigation and treatment with early geriatric rehabilitation. Discharge is planned already on the day of admission. The majority of the patients were referred from other medical departments of the hospital. This supports the theory that the Subacute Geriatric Department covers a hitherto unfulfilled requirement for early geriatric treatment among many elderly patients in medical departments.

Levels of complement receptor type one (CR1, CD35) on erythrocytes, circulating immune complexes and complement C3 split products C3d and C3c are not changed by short-term physical exercise or training.

The effect of heavy short-term physical exercise on the levels of complement receptor type one (CR1, CD35) on erythrocytes, the concentrations of circulating immune complexes (IC), and the complement C3 split products C3c and C3d were examined in young healthy males. Fourteen untrained volunteers underwent a 60-min bicycle exercise test at 75% of maximal oxygen uptake (VO2max). Six of the volunteers were exercised twice with an interval of at least one month. Before the second bicycle test they received oral indomethacin. With an interval of at least 1 week, 6 also went through a 60-min back-muscle exercise at up to 30% of VO2max. Blood samples were collected before and during the last few minutes of exercise as well as 2 h and 24 h afterwards. The same parameters were examined once in 29 highly trained racing cyclists. There were no consistent or significant exercise-induced changes in the levels of erythrocyte CR1, circulating IC, C3c nor C3d as measured by an enzyme-linked immunosorbent assay, polyethylene glycol precipitation complement consumption method, and by intermediate gel rocket immunoelectrophoresis, respectively. Neither did these parameters differ from controls in the highly trained group. The results indicate that CR1 on erythrocytes, circulating immune complexes and complement cleavage products C3c and C3d in healthy subjects remain unaffected by short-term heavy physical activity and training.

[Follow-up of elderly patients in their homes by general practitioners after discharge from hospital]. / Praktiserende laegers opfølgning i aeldres hjem efter hospitalsindlaeggelse.

The present project which is part of a more extensive coordination project has had the goal of carrying out and assessing the proposals about follow up home visits by the general practitioner after discharge from hospital made by "The coordinating committee for the health services". General practitioners in the municipality of Roskilde made a total of 210 visits to elderly patients aged 75 years or over who had been discharged to their homes after hospitalization for at least three days. During these visits, the practitioners discovered newly developed problems in 49% of the visits while adjustment of medication proved necessary at 52% of the visits. This investigation is concerned with the risk situation, viz discharge of elderly patients from hospital but it also attempts to identify the risk groups which obtain most benefit from follow up. The majority of problems were found among the oldest patients aged 85 years and over who had been hospitalized for more than seven days. In addition, the general practitioners found that significantly more elderly patients aged 85 years and over (less than or equal to 0.05) and elderly patients who had been hospitalized for over seven days should be followed up by home visits. It is emphasized that the model outlined here would not stress the individual general practitioner's daily routine to any great extent.

[Urinary symptoms in elderly women in nursing homes. Frequency and social consequences of urinary incontinence in elderly women living in nursing homes]. / Urinvejsgener hos gamle plejehjemsboende kvinder. Hyppighed og sociale konsekvenser af urin-inkontinens hos gamle plejehjemsboende kvinder.

All 278 female residents of nursing homes in the County of Roskilde were assessed as regards the extent and severity of urinary incontinence and possible urinary infections. A total of 168 (58.5%) were incontinent. Culture of the urine was performed in 210 women and significant bacteriuria was demonstrated in 50%. Thirty-four out of the total of 287 women (12%) had indwelling catheters. In incontinent women without catheters, great quantities of urine were often voided involuntarily. Despite this, only few were subjectively inconvenienced or inhibited in their social activities. The investigation revealed a connection between urinary incontinence and reduced mobility while no connection was observed with current urinary infections, intake of medicaments and parity. It is emphasized that these results are based on findings in very old women living in nursing homes.

Indomethacin in vitro and in vivo abolishes post-exercise suppression of natural killer cell activity in peripheral blood.

The present study was designed to explain the mechanism of the post-exercise down-regulation of human natural killer (NK) cell activity recently described by us. Fifteen young, healthy volunteers underwent 60 min of bicycle exercise at 75% of maximal oxygen uptake (VO2max). Six of the volunteers were exercised twice with an interval of at least one month. At the second exercise test they received oral indomethacin. Blood samples were collected before and during the last minutes of exercise as well as 2 h and 24 h after work. The NK cell activity (lysis fixed number of mononuclear cells) increased during bicycle exercise, dropped to a minimum 2 h later and returned to pre-exercise levels within 24 h. During bicycle exercise the percentage of NK cells (CD16+ cells) of mononuclear cells increased significantly but returned to normal within 2 h after exercise. Two hours after exercise, however, increased monocyte cell count and neutrophils were found. The in vitro release of prostaglandin E2 from mononuclear cells was increased. Furthermore, the neutrophil chemiluminescence response was also increased in the 2 h post-exercise period; this response is associated with prostaglandin E2 production by neutrophils. Indomethacin, whether administered in vivo or in vitro, fully restored the suppressed post-exercise NK cell activity. Finally, the NK cell activity of monocyte depleted mononuclear cells did not decrease below basal levels after exercise. These findings strongly indicate that prostaglandins released from monocytes and neutrophils are involved in the post-exercise down-regulation of NK cells.

Effect of physical exercise on blood mononuclear cell subpopulations and in vitro proliferative responses.

The present study was designed to examine the effect of physical exercise on subsets and proliferative responses of blood mononuclear cells. Sixteen young, healthy volunteers underwent 60 min of bicycle exercise at 75% of maximal oxygen uptake (VO2max). After an interval of at least 1 week, six of the subjects underwent a 60-min back muscle training period at up to 30% of VO2max. Blood samples were collected before and during the last minutes of exercise, as well as 2 and 24 h later. Blood mononuclear cell (BMNC) subpopulations were determined and the proliferative responses after incubation with phytohaemagglutinin (PHA) or purified derivative of tuberculin (PPD), were quantified by [3H]thymidine incorporation. During bicycle exercise the relative blood concentration of T cells (CD3+ cells) declined, mainly due to a fall in T helper cells (CD4+ cells). The natural killer (NK) cell subset (CD16+ cells) increased during work, but reverted after; the monocytes (CD14+ cells) increased 2 h after work, whereas the B-cell subset (CD20+ cells) did not change. BMNC subsets were not significantly changed by back muscle exercise. The PHA-induced proliferative response decreased during bicycle exercise, whereas the PPD-induced response did not change. No significant changes occurred during back muscle exercise. Investigation of subgroups after incubation with [3H]thymidine showed that the proliferative response per CD4+ cell did not change in relation to exercise, but the contribution of the CD4+ subgroup to proliferation declined during bicycle exercise due to the decreased proportion of CD4+ cells. The suppression of the PHA response during bicycle exercise can be explained in part by a relative fall in CD4+ cells. The pool sizes of BMNC subfraction may be elicited by increased catecholamine and cortisol levels.

Modulation of natural killer cell activity in peripheral blood by physical exercise.

The present study was designed to examine the effect of physical exercise on human natural killer (NK) cells. Six healthy volunteers underwent two different acute physical exercise tests with an interval of at least 1 week: (1) 60 min bicycle exercise at 80% of maximal oxygen uptake (VO2max) and (2) 60 min back-muscle training at up to 29% of VO2max; blood samples were collected before and during the last few minutes of exercise, as well as 2 h and 24 h afterwards. The NK cell activity (lysis/fixed number of mononuclear cells) increased during bicycle exercise, dropped to a minimum 2 h later and returned to pre-exercise levels within 24 h. Back-muscle exercise did not significantly influence NK cell activity. Plasma levels of adrenaline, noradrenaline, and cortisol were elevated during bicycling, but not during back-muscle exercise, indicating that exercise intensity is a determinant of NK cell activity. During bicycle exercise the NK cell subset (CD16- cells) of mononuclear cells increased significantly. Furthermore an improved interleukin 2 (IL-2) boosting of the NK cell activity was found during work as compared to IFN-alpha and indomethacin-enhanced NK cell activity. These results indicate that NK cells with a high IL-2 response capacity are recruited to the peripheral blood during exercise. The decreased NK cell activity demonstrated 2 h after work was probably not due to fluctuations in size of the NK cell pool, since the proportion of CD16+ cells was normal. The finding that indomethacin fully restored the suppressed NK cell activity in vitro and the demonstration of a twofold increase in monocyte (CD20+ cells) proportions 2 h after work, strongly indicate that prostaglandins released by monocytes during the heavy physical exercise are responsible for the down-regulation of the NK cells.