Building COPD care on shaky ground: a mixed methods study from Swedish primary care professional perspective.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is a public health problem. Interprofessional collaboration and health promotion interventions such as exercise training, education, and behaviour change are cost effective, have a good effect on health status, and are recommended in COPD treatment guidelines. There is a gap between the guidelines and the healthcare available to people with COPD. The aim of this study was to increase the understanding of what shapes the provision of primary care services to people with COPD and what healthcare is offered to them from the perspective of healthcare professionals and managers. METHODS: The study was conducted in primary care in a Swedish county council during January to June 2015. A qualitatively driven mixed methods design was applied. Qualitative and quantitative findings were merged into a joint analysis. Interviews for the qualitative component were performed with healthcare professionals (n = 14) from two primary care centres and analysed with qualitative content analysis. Two questionnaires were used for the quantitative component; one was answered by senior managers or COPD nurses at primary care centres (n = 26) in the county council and the other was answered by healthcare professionals (n = 18) at two primary care centres. The questionnaire data were analysed with descriptive statistics. RESULTS: The analysis gave rise to the overarching theme building COPD care on shaky ground. This represents professionals driven to build a supportive COPD care on 'shaky' organisational ground in a fragmented and non-compliant healthcare organisation. The shaky ground is further represented by uninformed patients with a complex disease, which is surrounded with shame. The professionals are autonomous and pragmatic, used to taking responsibility for their work, and with limited involvement of the management. They wish to provide high quality COPD care with interprofessional collaboration, but they lack competence and are hindered by inadequate routines and lack of resources. CONCLUSIONS: There is a gap between COPD treatment guidelines and the healthcare that is provided in primary care. To facilitate implementation of the guidelines several actions are needed, such as further training for professionals, additional resources, and improved organisational structure for interprofessional collaboration and patient education.

Physical Activity Levels Among Adolescent and Young Adult Women and Men with and without Intellectual Disability.

BACKGROUND: As physical activity can prevent overweight and promote general health, the aim was to investigate the amount of physical activity among adolescent and young adult women and men with intellectual disability (ID), compared to age-matched control groups without intellectual disability. A further aim was to examine whether physical activity level was associated with the body mass index (BMI). MATERIALS AND METHODS: Fifty-two adolescent and young adult women and men with intellectual disability and 48 without intellectual disability, between the ages 16 and 20 years, BMIs ranging from 16.3 to 50.3 kg/m(2) , were measured for number of steps taken with a pedometer for five consecutive days (Sunday-Thursday). RESULTS: The only group to meet recommendations regarding number of steps (10 000-12 000/day) was women without intellectual disability. No significant associations were found between total number of steps taken and BMI. CONCLUSION: As the majority of adolescents and young adults with intellectual disability, especially women, did not reach recommended activity levels regardless of their BMIs, this call for broad measures to increase physical activity.

Correlations between Ratings and Technical Measurements in Hand-Intensive Work.

An accurate rating of hand activity and force is essential in risk assessment and for the effective prevention of work-related musculoskeletal disorders. However, it is unclear whether the subjective ratings of workers and observers correlate to corresponding objective technical measures of exposure. Fifty-nine workers were video recorded while performing a hand-intensive work task at their workplace. Self-ratings of hand activity level (HAL) and force (Borg CR10) using the Hand Activity Threshold Limit Value® were assessed. Four ergonomist observers, in two pairs, also rated the hand activity and force level for each worker from video recordings. Wrist angular velocity was measured using inertial movement units. Muscle activity in the forearm muscles flexor carpi radialis (FCR) and extensor carpi radialis (ECR) was measured with electromyography root mean square values (RMS) and normalized to maximal voluntary electrical activation (MVE). Kendall's tau-b correlations were statistically significant between self-rated hand activity and wrist angular velocity at the 10th, 50th, and 90th percentiles (0.26, 0.31, and 0.23) and for the ratings of observers (0.32, 0.41, and 0.34). Significant correlations for force measures were found only for observer-ratings in five of eight measures (FCR 50th percentile 0.29, time > 10%MVE 0.43, time > 30%MVE 0.44, time < 5% -0.47) and ECR (time > 30%MVE 0.26). The higher magnitude of correlation for observer-ratings suggests that they may be preferred to the self-ratings of workers. When possible, objective technical measures of wrist angular velocity and muscle activity should be preferred to subjective ratings when assessing risks of work-related musculoskeletal disorders.

Does daily exposure to whole-body vibration and mechanical shock relate to the prevalence of low back and neck pain in a rural workforce?

OBJECTIVES: To determine whether whole-body vibration (WBV) and mechanical shock exposure from quad bike use are associated with the prevalence of neck and low back pain (LBP) in New Zealand farmers and rural workers. METHODS: Full-day WBV and mechanical shock exposures were gathered from 130 farmers and rural workers. Participants were surveyed for a history of neck or LBP in the past 7 days and in the past 12 months. Anthropometric, personal, and workplace data were also gathered. RESULTS: Physical exposures (mechanical shocks), employee status, and low levels of workplace satisfaction are all significantly associated with the 12-month prevalence of LBP in this rural workforce that regularly use quad bikes. Both vibration and mechanical shock exposure were strongly associated with 12-month prevalence of neck pain. The 7-day prevalence of neck pain showed a non-significant association with mechanical shock and vibration. CONCLUSIONS: Knowledge of these findings will be valuable information for those who teach and advise on safe driving techniques for such vehicles in the rural workplace where reduction of physical exposures and injury rates is of high importance.

Ratings of Hand Activity and Force Levels among Women and Men Who Perform Identical Hand-Intensive Work Tasks.

We compared hand activity and force ratings in women and men doing identical hand-intensive work tasks. Musculoskeletal disorders are more common in women and hand-intensive work leads to an increased risk of these disorders. Knowledge of the gender influence in the rating of work exposure is lacking. The aim of this study was to investigate whether women and men performing identical hand-intensive work tasks were equally rated using hand activity and normalized peak force levels with the Hand Activity Threshold Limit Value®. Fifty-six workers participated, comprising 28 women-men pairs. Four observers-two woman-man pairs-were also involved. Self-ratings and observers' ratings of hand activity and force level were collected. The results of these ratings showed no significant gender differences in self-rated hand activity and force, as well as observer-rated hand activity. However, there was a significant gender difference in the observer-rated force, where the women were rated higher (mean (SD): women 3.9 (2.7), men 3.1 (1.8) (p = 0.01)). This difference remained significant in the adjusted model (p = 0.04) with grip strength and forearm-finger anthropometrics. The results provide new insights that observers' estimates of force can be higher in women compared with men in the same work tasks. Force should be further investigated and preferably compared to objective measurements.

Exposure to whole-body vibration and mechanical shock: a field study of quad bike use in agriculture.

OBJECTIVES: The purpose of this study was to determine exposure to whole-body vibration (WBV) and mechanical shock in rural workers who use quad bikes and to explore how personal, physical, and workplace characteristics influence exposure. METHODS: A seat pad mounted triaxial accelerometer and data logger recorded full workday vibration and shock data from 130 New Zealand rural workers. Personal, physical, and workplace characteristics were gathered using a modified version of the Whole Body Vibration Health Surveillance Questionnaire. WBVs and mechanical shocks were analysed in accordance with the International Standardization for Organization (ISO 2631-1 and ISO 2631-5) standards and are presented as vibration dose value (VDV) and mechanical shock (S(ed)) exposures. RESULTS: VDV(Z) consistently exceeded European Union (Guide to good practice on whole body vibration. Directive 2002/44/EC on minimum health and safety, European Commission Directorate General Employment, Social Affairs and Equal Opportunities. 2006) guideline exposure action thresholds with some workers exceeding exposure limit thresholds. Exposure to mechanical shock was also evident. Increasing age had the strongest (negative) association with vibration and shock exposure with body mass index (BMI) having a similar but weaker effect. Age, daily driving duration, dairy farming, and use of two rear shock absorbers created the strongest multivariate model explaining 33% of variance in VDV(Z). Only age and dairy farming combined to explain 17% of the variance for daily mechanical shock. Twelve-month prevalence for low back pain was highest at 57.7% and lowest for upper back pain (13.8%). CONCLUSIONS: Personal (age and BMI), physical (shock absorbers and velocity), and workplace characteristics (driving duration and dairy farming) suggest that a mix of engineered workplace and behavioural interventions is required to reduce this level of exposure to vibration and shock.

Patient expectations about a clinical diagnostic test may influence the clinician's test interpretation.

BACKGROUND: With medical information widely available, patients often have preconceived ideas regarding diagnostic procedures and management strategies. OBJECTIVES: To investigate whether expectations, such as beliefs about the source of symptoms and knowledge about diagnostic tests, influence pain perception during a clinical diagnostic test. DESIGN: Cross-sectional study. METHODS: Pain was induced by intramuscular hypertonic saline infusion in the thenar muscles. In line with sample size calculations, fifteen participants were included. All participants received identical background information regarding basic median nerve biomechanics and basic concepts of differential diagnosis via mechanical loading of painful structures. Based on different explanations about the origin of their induced pain, half of the participants believed (correctly) they had 'muscle pain' and half believed (incorrectly) they had 'nerve pain'. Pain intensity and size of the painful area were evaluated in five different positions of the median nerve neurodynamic test (ULNT1 MEDIAN). Data were analysed with two-way analyses of variance. RESULTS: /findings: Changes in pain in the ULNT1 MEDIAN positions were different between the 'muscle pain' and 'nerve pain' group (p < 0.001). In line with their expectations, the 'muscle pain' group demonstrated no changes in pain throughout the test (p > 0.38). In contrast, pain intensity (p ≤ 0.003) and size of the painful area (p ≤ 0.03) increased and decreased in the 'nerve pain' group consistent with their expectations and the level of mechanical nerve loading. CONCLUSION: Pain perception during a clinical diagnostic test may be substantially influenced by pain anticipation. Moreover, pain was more aligned with beliefs and expectations than with the actual pathobiological process.

Double-Sided Mechanical Shocks Provoke Larger Seated Postural Reactions Compared With Single-Sided Mechanical Shocks.

STUDY DESIGN: Human volunteers were exposed experimentally to single-sided mechanical shocks (SSMS) and double-sided mechanical shocks (DSMS) while seated. OBJECTIVE: The aim of this study was to describe and contrast seated postural reactions due to SSMS or DSMS in healthy male adults. SUMMARY OF BACKGROUND DATA: Mechanical shocks to the body, caused when driving on irregular terrain, are suggested to be hazardous to the spine and may be associated with the reported musculoskeletal pain of the back and neck among professional drivers. However, very little is known about the characteristics of seated postural reactions and the biomechanical effects caused by mechanical shocks. METHODS: Twenty healthy male subjects (18-43 years old) were exposed while seated to 5 SSMS and 15 DSMS in lateral directions. The second acceleration in the DSMS was in the opposite direction to the first acceleration and was fast, medium, or slow depending on the speed of direction change. Surface electromyography (EMG) was recorded in muscles of the upper neck, trapezius, erector spinae, and external oblique, while kinematics were recorded with inertial sensors placed at the neck, trunk, and pelvis. Muscle activity was normalized to maximum voluntary contractions (MVCs). RESULTS: The EMG amplitudes were significantly higher (0.6-1%; P < 0.001) for the fast DSMS than all other shocks. Range of motion (ROM) of the neck and trunk was greater during the DSMS than the SSMS. Evoked muscle activity was less than 2% MVC in the trapezius, less than 10% MVC in the erector spinae and upper neck, while the activity exceeded 10% MVC in the external oblique muscles. CONCLUSION: Fast DSMS in lateral directions appear more demanding than SSMS, demonstrating augmented seated postural reactions. However, the present mechanical shocks employed did not seem to induce postural reactions with regard to ROM or muscle activity of a magnitude likely to cause musculoskeletal overload. LEVEL OF EVIDENCE: 4.

Hand-arm vibration syndrome (HAVS) and musculoskeletal symptoms in the neck and the upper limbs in professional drivers of terrain vehicles--a cross sectional study.

This study compares the prevalence of symptoms of Hand-arm vibration syndrome (HAVS) and musculoskeletal symptoms in the neck and the upper limbs, between professional drivers of terrain vehicles and a referent group. 769 male professional drivers of forest machines, snowmobiles, snowgroomers and reindeer herders and 296 randomly selected male referents completed a questionnaire about symptoms of HAVS and musculoskeletal symptoms in the neck and the upper limbs. They also gave information about their lifetime exposure duration driving terrain vehicles and their nicotine use. Prevalence odds ratios (POR) were determined and adjusted for age and nicotine use. Results show that there is a relation between exposure to driving terrain vehicles and some of the symptoms of HAVS (POR: 1.2-6.1). Increased odds of musculoskeletal symptoms in neck, shoulders and wrists were also found (POR 1.2-6.4), and it seemed to be related to the cumulative exposure time.

Telehealthcare in COPD: a systematic review and meta-analysis on physical outcomes and dyspnea.

BACKGROUND: Only a minority of patients with chronic obstructive pulmonary disease (COPD) have access to pulmonary rehabilitation (PR). Home-based solutions such as telehealthcare, have been used in efforts to make PR more available. The aim of this systematic review was to investigate the effects of telehealthcare on physical activity level, physical capacity and dyspnea in patients with COPD, and to describe the interventions used. METHODS: Randomized controlled trials were identified through database searches, reference lists and included authors. Articles were reviewed based on eligibility criteria by three authors. Risk of bias was assessed by two authors. Standardized mean differences (SMD) or mean differences (MD) with 95% CI were calculated. Forest plots were used to present data visually. RESULTS: Nine studies (982 patients) were included. For physical activity level, there was a significant effect favoring telehealthcare (MD, 64.7 min; 95% CI, 54.4-74.9). No difference between groups was found for physical capacity (MD, -1.3 m; 95% CI, -8.1-5.5) and dyspnea (SMD, 0.088; 95% CI, -0.056-0.233). Telehealthcare was promoted through phone calls, websites or mobile phones, often combined with education and/or exercise training. Comparators were ordinary care, exercise training and/or education. CONCLUSIONS: The use of telehealthcare may lead to improvements in physical activity level, although the results should be interpreted with caution given the heterogeneity in studies. This is an important area of research and further studies of the effect of telehealthcare for patients with COPD would be beneficial. REGISTRATION: In PROSPERO 2012: CRD42012003294. STUDY PROTOCOL: http://www.crd.york.ac.uk/PROSPEROFILES/3294_PROTOCOL_20121016.pdf.

Neuromusculoskeletal disorders in the neck and upper extremities among drivers of all-terrain vehicles--a case series.

BACKGROUND: The purpose of this study was to investigate whether professional drivers of all-terrain vehicles (ATVs) with neck pain have a different array of neuromusculoskeletal disorders in the neck and upper extremities than a referent group with neck pain from the general population. It is hypothesized that exposure to shock-type vibration and unfavorable working postures in ATVs have the capacity to cause peripheral nervous lesions. METHODS: This study was based on a case series analyzed according to a case-case comparison design. The study population consisted of 60 male subjects, including professional drivers of forest machines (n = 15), snowmobiles (n = 15), snowgroomers (n = 15) and referents from the general population (n = 15) all of whom had reported neck pain in a questionnaire and underwent an extensive physical examination of the neck and upper extremities. Based on symptom history, symptoms and signs, and in some cases chemical, electroneurographical and radiological findings, subjects were classified as having a nociceptive or neuropathic disorder or a mix of these types. RESULTS: The occurrence of asymmetrical and focal neuropathies (peripheral nervous lesion), pure or in a mix with a nociceptive disorder was common among cases in the ATV driver groups (47%-79%). This contrasted with the referents that were less often classified as having asymmetrical and focal neuropathy (27%), but instead had more nociceptive disorders. The difference was most pronounced among drivers of snowgroomers, while drivers of forest machines were more frequently classified as having a nociceptive disorder originating in the muscles. CONCLUSION: This study found a high prevalence of assymetrical and focal neuropathies among drivers with pain in the neck, operating various ATVs. It seems as if exposure to shock-type whole-body vibration (WBV) and appurtenant unfavorable postures in ATVs may be associated to peripheral nervous lesions.

Postural muscle responses and adaptations to backward platform perturbations in young people with and without intellectual disability.

This study examines postural muscle responses to backward perturbations in young people (16-20 years) with and without intellectual disability (ID). The study included 56 young people with ID and 43 age-matched without ID volunteers. The subjects stood on a platform that was moved backwards in a surface translation. Lower and upper leg muscles and lower back spine muscles were recorded with surface electromyography (EMG). Muscle onset latency, time to peak amplitude (EMG), adaptation of muscle responses to repeated perturbations (using integrated EMG (IEMG) for epochs), and synergies and strategies were assessed. The result showed no differences between the two groups in muscle onset latency, synergies, and strategies. Young people with ID reduced their time to peak amplitude in investigated muscles, a response that was different from the group without ID. Also, young people with ID tended to adapt their IEMG less compared to the controls. These findings suggest that young people with ID have limited ability to use somatosensory information and adapt their postural muscle responses to repeated external perturbations.

Adolescents with intellectual disability have reduced postural balance and muscle performance in trunk and lower limbs compared to peers without intellectual disability.

For adolescent people with ID, falls are more common compared to peers without ID. However, postural balance among this group is not thoroughly investigated. The aim of this study was to compare balance and muscle performance among adolescents aged between 16 and 20 years with a mild to moderate intellectual disability (ID) to age-matched adolescents without ID. A secondary purpose was to investigate the influence of vision, strength, height and Body Mass Index (BMI) on balance. A group of 100 adolescents with ID and a control group of 155 adolescents without ID were investigated with five balance tests and three strength tests: timed up and go test, one leg stance, dynamic one leg stance, modified functional reach test, force platform test, counter movement jump, sit-ups, and Biering-Sørensen trunk extensor endurance test. The results showed that adolescents with an ID in general had significantly lower scores in the balance and muscle performance tests. The group with ID did not have a more visually dominated postural control compared to the group without ID. Height, BMI or muscle performance had no strong correlations with balance performance. It appears as if measures to improve balance and strength are required already at a young age for people with an ID.

Test-retest reliability, smallest real difference and concurrent validity of six different balance tests on young people with mild to moderate intellectual disability.

OBJECTIVES: Some studies have reported that people with intellectual disability may have reduced balance ability compared with the population in general. However, none of these studies involved adolescents, and the reliability and validity of balance tests in this population are not known. The purpose of this study was to examine the reliability of six different balance tests and to investigate their concurrent validity. DESIGN: Test-retest reliability assessment. SETTINGS: All subjects were recruited from a special school for people with intellectual disability in Bollnäs, Sweden. PARTICIPANTS: Eighty-nine adolescents (35 females and 54 males) with mild to moderate intellectual disability with a mean age of 18 years (range 16 to 20 years). INTERVENTIONS: All subjects followed the same test protocol on two occasions within an 11-day period. MAIN OUTCOMES: Balance test performances. RESULTS: Intraclass correlation coefficients greater than 0.80 were achieved for four of the balance tests: Extended Timed Up and Go Test, Modified Functional Reach Test, One-leg Stance Test and Force Platform Test. The smallest real differences ranged from 12% to 40%; less than 20% is considered to be low. Concurrent validity among these balance tests varied between no and low correlation. CONCLUSION: The results indicate that these tests could be used to evaluate changes in balance ability over time in people with mild to moderate intellectual disability. The low concurrent validity illustrates the importance of knowing more about the influence of various sensory subsystems that are significant for balance among adolescents with intellectual disability.

All-terrain vehicle use in agriculture: exposure to whole body vibration and mechanical shock.

Whole body vibration (WBV) and mechanical shock were measured in 12 New Zealand farmers during their daily use of all-terrain vehicles (ATVs). As per the International Organization for Standardization (ISO) guidelines for WBV exposure, frequencies between 0 and 100Hz were recorded via a seat-pad tri-axial accelerometer during 20min of ATV use. The farmers were also surveyed to estimate seasonal variation in daily ATV usage as well as 7-day and 12-month prevalence of spinal pain. Frequency-weighted vibration exposure and total riding time were calculated to determine the daily vibration dose value (VDV). The daily VDV of 16.6m/s(1.75) was in excess of the 9.1m/s(1.75) action limit set by ISO guidelines suggesting an increased risk of low back injury from such exposure. However, the mean shock factor R, representing cumulative adverse health effects, was 0.31 indicating that these farmers were not exposed to excessive doses of mechanical shock. Extrapolation of daily VDV data to estimated seasonal variations of farmers in ATV riding time demonstrated that all participants would exceed the ISO recommended maximum permissible limits during the spring lambing season, as compared to lower exposures calculated for summer, autumn and winter. Low back pain was the most commonly reported complaint for both 7 day (50%) and 12 month prevalence (67%), followed by the neck (17% and 42%) and the upper back (17% and 25%) respectively. The results demonstrate high levels of vibration exposure within New Zealand farmers and practical recommendations are needed to reduce their exposure to WBV.

Whole-body vibration exposure and non-neutral neck postures during occupational use of all-terrain vehicles.

OBJECTIVES: The purpose of this study was to characterize whole-body vibration (WBV) exposure from various all-terrain vehicles (ATVs) like snowgroomers, snowmobiles and forwarders, and to investigate how frequently the drivers' cervical spine is positioned in a non-neutral rotational position during operation. METHODS: Field measurements of WBV were measured according to the international standard ISO 2631-1 in 19 ATVs. Simultaneous recordings of frequency and duration of rotational neck movements exceeding 15 degrees were achieved through an observational method, PEOflex. RESULTS: The sum of the vectors of frequency-weighted r.m.s. acceleration varied between 0.5 and 3.5 m s(-2), which meant that for most vehicles they exceeded the action value stated by the European Union (0.5 m s(r.m.s.)(-2)). In general, snowmobiles achieved the highest vibration total value. The dominant vibration direction for the snowmobile was the x-axis but the z-axis also had relatively high vibration dose values and maximal transient vibration values. The z-axis was the dominant vibration direction for the snowgroomer and the y-axis for the forwarder. Frequency and duration of non-neutral rotational neck postures were relatively low for all driver categories. CONCLUSIONS: Vibration magnitudes in ATVs are considerably high than the EU's action value and the health guidance caution zones in ISO 2631-1. The dominant vibration direction varies depending on the machine type. Duration and frequency of non-neutral rotational positions do not seem to constitute single ergonomic risk factors for musculoskeletal symptoms in the neck among professional drivers of ATVs. However, synergistic effects with other factors are conceivable.

Osteoarthritis in the hip and whole-body vibration in heavy vehicles.

BACKGROUND: Farmers have an increased risk of osteoarthritis in the hip, but the mechanism is not known. It has been suggested that the driving of tractors and jumping up and down from the tractor cabin is of importance. In this study, we test the hypothesis that driving vehicles with high levels of whole-body vibration (WBV) is associated with an increased risk of osteoarthritis in the hip. METHODS: This is a cohort study of male operators of heavy vehicles working in the construction industry. They participated in a national health control program. The incidence rate for joint replacement in the hip was found in the Swedish Hospital Discharge Register for 1987 to 1998 and compared with the incidence in reference groups. Their exposure to WBV was estimated from their job titles. The rates were adjusted to body mass index (BMI) and smoking habits and compared to referents participating in the same health control program. RESULTS: Drivers exposed to WBV had not an increased risk of joint replacement due to osteoarthritis in the hip (RR = 0.82; 95% CI 0.51-1.24). CONCLUSIONS: This study does not support the hypothesis that exposure to WBV during operating a vehicle cause an increased risk of osteoarthritis in the hip.