Managing pain and fatigue in people with spinal cord injury: a randomized controlled trial feasibility study examining the efficacy of massage therapy.

STUDY DESIGN: A randomized controlled trial (RCT). OBJECTIVES: To determine the efficacy of massage therapy (MT) as a treatment that could be implemented to reduce pain and fatigue in people with chronic spinal cord injury (SCI). SETTING: Laboratory setting in Sydney, Australia. METHODS: Participants included 40 people with SCI living in the community who were randomly assigned into one of two RCT arms: MT (Swedish massage to upper body) or an active concurrent control (guided imagery (GI) relaxation). All participants received 30 min once a week of either massage or GI over 5 consecutive weeks. In addition to sociodemographic and injury factors, assessments and reliable measures including the short-form McGill Pain Questionnaire and Chalder's Fatigue Scale were validated. RESULTS: Chronic pain and fatigue were significantly reduced in the massage group when assessed at the end of 5 weeks (P<0.05), with large effect sizes. Interestingly, GI was as effective as MT in reducing pain and fatigue. Pain scores were reduced significantly over time in both MT and GI groups (P=0.049 and P=0.032, respectively). Total fatigue scores were also reduced in both MT and GI groups (P=0004 and P=0.037, respectively.)Conclusions:Massage and GI are both active treatments that provide potential clinical benefits for adults with SCI. Future research should clarify the role of massage and GI in managing pain and fatigue in SCI and assess outcomes into the longer-term.

Developing an algorithm capable of discriminating depressed mood in people with spinal cord injury.

STUDY DESIGN: Cross-section design. OBJECTIVES: The development of reliable screen technology for predicting those at risk of depression in the long-term remains a challenge. The objective of this research was to determine factors that classify correctly adults with spinal cord injury (SCI) with depressed mood and to develop a diagnostic algorithm that could be applied for prediction of depressed mood in the long-term. SETTING: SCI rehabilitation unit, rehabilitation outpatient clinic and Australian community. METHODS: Participants included 107 adults with SCI. The assessment regimen included demographic and injury variables, negative mood states, pain intensity, health-related quality of life and self-efficacy. Participants were divided into those with 'normal' mood versus those with elevated depressed mood. Discriminant function analysis (DFA) was then used to isolate factors that in combination, best classify the presence or absence of depressed mood. RESULTS: At the time of assessment, 24 participants (22.4%) had elevated depressed mood. DFA identified six factors that discriminated between those with depressed mood (P<0.01) and those with normal mood, explaining 61% of the variance. Factors consisted of pain intensity, mental health, emotional and social functioning, self-efficacy and fatigue. DFA correctly classified 91.7% (n=22 of 24) of those with depressed mood and 95.2% (n=79 of 83) of those without. Demographic, injury and physical health function variables were not found to discriminate depressed mood. CONCLUSION: Clinical implications of applying a diagnostic algorithm for detecting depression in adults with SCI are discussed. Prospective research is needed to test the predictive efficacy of the algorithm.

A controlled trial investigating the effect of music therapy during an acute psychotic episode.

OBJECTIVE: To investigate the effects of music therapy, as an adjunct to pharmacological therapy during an acute psychotic episode. METHOD: Sixty participants were quasi-randomised into either a treatment or control group. Standardised psychological assessments [Brief Psychiatric Rating Scale (BPRS), Calgary Interview Guide for Depression, Nurses' Observation Scale for Inpatient Evaluation (NOSIE-30) and Depression Anxiety Stress Scale (DASS21)] were conducted before and after the sessions to determine whether there were any significant changes in outcomes. RESULTS: Statistically significant changes in BPRS scores were seen in the treatment group (n = 25) compared with the control group (n = 24). No significant differences were seen in the results of the Calgary, NOSIE-30 or DASS21 scores. Despite the treatment group, having a 9.3% decrease in their length of stay in hospital as opposed to the control group, this did not reach statistical significance. No significant differences were found when comparing the two groups in their doses of antipsychotic, benzodiazepine, mood stabilising or antidepressant medication or at the 1-month follow-up assessment. CONCLUSION: Most of the variables tested in our study but one did not point at any advances of adding music therapy to pharmacological treatment. The finding of improvement in Brief Psychiatric Rating Scale could be an indicator of music therapy as a useful adjunct to pharmacotherapy during an in-patient hospital stay for the few patients amongst those suffering acute psychosis that accept to participate in music therapy.

Prospective study of early bereavement on psychological and behavioural cardiac risk factors.

BACKGROUND: Increasing evidence supports the role of emotional stress in the onset of cardiovascular disease. Although bereavement is a major emotional stress with both acute and more long-term features, the mechanism of its association with cardiovascular risk is not well understood, in particular because of limited studies of acute bereavement. The aim of the study was to identify psychological and behavioural changes in acute bereavement and potential modifiers of these changes. METHODS: Bereaved (n= 62) and non-bereaved individuals (n= 50) were evaluated within 2 weeks and at 6 months following loss using the Centre for Epidemiologic Studies -- Depression, Spielberger State Anxiety and Anger, Social Support Questionnaire and changes in appetite, cigarette and alcohol consumption, cortisol and lipids. RESULTS: Compared with non-bereaved, acutely bereaved had increased symptoms of depression (26.7 +/- 1.7 vs 5.9 +/- 0.7, P < 0.001), anxiety (47.4 +/- 2.0 vs 28.2 +/- 1.4, P < 0.001) and anger (median 16.0 vs 15.0, P < 0.001). Greater depressive symptoms were associated with being unprepared for the death, decreased sleep duration and younger age. Acutely, bereaved slept less than non-bereaved (5.8 +/- 0.2 vs 7.2 +/- 0.2 h, P < 0.001). Reduced sleep time was associated with increased anger and depression and decreased satisfaction with social support. Compared with the non-bereaved, the acutely bereaved had higher cortisol (median 306 vs 266, P= 0.003), reduced appetite (P < 0.001) and lower total cholesterol (median 4.9 vs 5.4, P= 0.006) and low-density lipoprotein (median 2.4 vs 2.9, P < 0.001). CONCLUSION: These results offer insight into the psychological, behavioural and physical changes that may contribute to cardiovascular risk in bereavement.

Spinal cord and related injuries after attempted suicide: psychiatric diagnosis and long-term follow-up.

STUDY DESIGN: Retrospective analysis of acute spinal cord injuries (ASCI). OBJECTIVES: Determine incidence of ASCI due to suicide attempt from 1970 to 2000. Describe demographics, injuries, mental illness, functional outcomes and nature of subsequent deaths. SETTING: State spinal cord injury services, New South Wales, Australia. METHODS: Retrospective record review and follow-up interview. RESULTS: Of 2752 ASCI admissions, 56 were because of attempted suicide (55 falls, one gun-shot wound). Thirty-six males and 20 females. Median age 30 years (15-74). Most common levels of vertebral injury were C5 and L1. Twenty-three had complete spinal cord injury. Thirty-two had an Injury Severity Score of >15. Forty had more than one major injury. There was a significant rise in the incidence of ASCI following self-harm over time (Poisson regression, P=0.004). There was a significant change in scene of injury away from hospitals over time (chi (2) test, df=1, P=0.0001). Psychiatric diagnoses were personality disorder 27; schizophrenia 16; depression 14; chronic alcohol abuse 10; mood disorder 10; chronic substance abuse 10; other four. Follow-up was available in 47 cases (84%) at an average of 8 years. Four subsequent deaths were by suicide. Domiciliary arrangements were: home 28; hospital five; nursing home three; group home/hostel four. CONCLUSIONS: Community placement outcomes for survivors were good. Subsequent death by suicide was high. There was a significant rise in cases and a change in injury scene away from hospitals over time.

Placebo-controlled biofeedback blood pressure effect in hypertensive humans.

The role of biofeedback in blood pressure control remains ill-defined because of nonspecific (placebo) effects, small study numbers, and the technical limitations of continuous pressure feedback. Clarification of its potential is awaited by those seeking a nonpharmacological approach to blood pressure control. This study examines the capability for systolic pressure lowering of 5 mm Hg or more using continuous pressure feedback in a statistical sample of untreated, well-characterized, mildly hypertensive individuals. Subjects were randomized in a double-blind study to active or placebo biofeedback. Placebo consisted of a modified contingency approach, using a partial disguise based on a digital high pass filter with 15 elements. Blood pressure-lowering capability was assessed during two laboratory sessions. Continuous visual feedback resulted in 11 of 28 subjects on active treatment and 12 of 28 on placebo treatment lowering their systolic pressure by 5 mm Hg or more (11 +/- 5.6 and 12 +/- 8.4 mm Hg, respectively; P = NS). Prestudy pressure was well-matched (153 +/- 9/97 +/- 4 and 154 +/- 8/98 +/- 4 mm Hg, respectively). An initial small difference in diurnal profile did not change. These findings indicate that among mildly hypertensive individuals, almost half can lower systolic pressure at will for short periods. This capability is independent of the real or placebo nature of the feedback signal. We conclude that there is no specific short-term biofeedback pressure-lowering capability in hypertensive individuals. Further exploration is needed to determine whether specific components of the placebo effect can be delineated, whether personality characteristics influence the response, and whether further biofeedback training can alter the outcome.

Deliberate overdose of uranium: toxicity and treatment.

A case is described of deliberate ingestion of 15 g of uranium acetate which resulted in acute renal failure requiring dialytic therapy for 2 weeks, refractory anaemia, rhabdomyolysis, myocarditis, liver dysfunction with a disproportionate coagulopathy and paralytic ileus. Despite significant elevations in plasma uranium levels, treatment with both calcium EDTA and calcium DTPA were ineffective in promoting uranium excretion. Six months later the initial significant renal impairment exists with a persistent incomplete Fanconi syndrome. Future options for management of this unusual cause of acute renal failure are discussed.

Voluntary blood pressure control by biofeedback: relationship to psychological characteristics.

1. Psychological characteristics were studied in 25 hypertensives (mean and standard deviation of blood pressure 150/95 +/- 12/5 mmHg), who received blood pressure (BP) biofeedback (BFB). Personality factors and success in BFB-BP modifying ability were correlated and the predictive value of psychological factors was estimated. 2. Questionnaires consisted of a Locus of Control of Behaviour (LCB) scale, the Spielberger state trait anxiety inventory and the Framingham Type A personality inventory. 3. BP was monitored continuously from the finger by volume clamp plethysmography during eight BFB sessions, each with three trials of raising, ignoring and lowering systolic blood pressure (SP). 4. SP was raised/lowered by 12 +/- 11/6 +/- 9 mmHg and heart rate (HR) increased by 10 +/- 3.9/+ 1 +/- 6.1. Ten subjects were able to lower SP by greater than or equal to 5 mmHg (15 +/- 7.5) and raise it by 17 +/- 11. The others achieved no decrease in SP and were also less successful at raising (8 mmHg, P = 0.04). 5. Changes in LCB and trait anxiety correlated with DP rise, whereas type A and pre-study state anxiety correlated with rising HR. Lowering of SP correlated weakly with change in LCB (r = 0.47, P = 0.06). 6. Combinations of psychological factors had independent predictive value for BP and HR change: trait anxiety (P = 0.03) and change in LCB (P = 0.009) with rise in diastolic blood pressure (DP); type A (P = 0.009), pre-study LCB (P = 0.02) and pre-study state anxiety (P = 0.01) with HR rise.(ABSTRACT TRUNCATED AT 250 WORDS)

Voluntary blood pressure control using continuous systolic blood pressure biofeedback.

1. Ability to alter blood pressure (BP) acutely with continuous systolic (SBP) BP biofeedback was assessed in volunteers using a new non-invasive finger BP monitor. 2. Reliability of finger BP measurement was demonstrated in six hypertensive subjects (21-60 years), by beat-to-beat comparison with brachial intra-arterial BP over 90 min. Wide variation of BP was achieved by physiological manoeuvres. Mean error of finger BP was -3.0/-2.2 mmHg with intra-subject s.d. of 7.2/5.4 mmHg. 3. Thirteen normotensives (21-51 years) were paid to undergo 30 trials of SBP biofeedback in six sessions over 3 weeks. The SBP trend was displayed on a monitor with appropriately 'shaped' targets; each trial consisted of BP-raising and -lowering periods of 45 and 90 s respectively with intervening 45 s baselines. 4. Nine subjects raised BP, on analysis of the last 10 trials, by an average of 18.8 mmHg while five of the 13 successfully lowered BP by an average of 10.0 mmHg. BP lowering was best achieved by diminishing respiratory rate and depth, and muscular relaxation. 5. Demonstration of large BP reductions in five of 13 normotensives using strategies applicable to longer training sessions warrants further investigations in hypertensive subjects, focusing on mediating mechanisms and transfer of effect beyond the laboratory.

Clinical course and outcome of severe head injury in Australia.

The records of 159 severely head-injured patients (all in coma for longer than 6 hours) from Sydney, Australia, were studied. The clinical course, charted over a 2-week period, indicated that 60% of deaths occur by Day 3 and that 12% of patients remain in coma (Glagow Coma Scale (GCS) score less than 7) for more than 2 weeks. Overall, at long-term follow-up review more than 2 years after injury, 51% of patients were dead, 7% were severely disabled or vegetative, and 42% had a good to moderate recovery. Outcome of the patients in prolonged coma was assessed separately, with only one-third making a good or moderate recovery; two-thirds of the severely disabled patients came from this group. The high proportion of poor outcomes associated with prolonged coma suggests that this group of patients should be specifically targeted in research. One appropriate intervention with this group would be the restructuring and intensification of early rehabilitation. However, the GCS score lacks the precision needed for this type of study, and a better measure of recovery should be developed.

Participation in faecal occult blood screening for colorectal cancer.

Chemical faecal occult blood testing has been proposed as a means of screening for colorectal cancer (C.C.) in populations or in identified high-risk groups. The level of public participation is a critical factor in the effectiveness of screening programmes. This study was conducted as a methodological pretest for an intended investigation of factors influencing screening participation. Faecal occult blood screening was offered to 728 employees of a teaching hospital in Sydney, New South Wales and 41% participation was obtained. Both participants and non-participants were questioned on demographic and social background factors, on their experience of C.C. in others, and on their reasons for participating or not participating. Major reasons for participation were: a general feeling of the importance of health checks and screening tests; a belief that it is important to diagnose C.C. early; and the fact that the test was simple and easy to do. Prominent self-acknowledged reasons for non-participation were indifference, procrastination, absence of previous bowel complaints, preference for one's own doctor to do such tests and inconvenience or lack of time. Those more likely to participate were: females; those of Australian or British origin; single, separated or divorced persons; those having two or more dependents and those with personal knowledge of a C.C. patient.

Depressed lymphocyte function after bereavement.

During 1975 twenty-six bereaved spouses took part in a detailed prospective investigation of the effects of severe stress on the immune system. T and B cell numbers and function, and hormone concentrations were studied approximately 2 weeks after bereavement and 6 weeks thereafter. The response to phytohaemagglutinin was significantly depressed in the bereaved group on the second occasion, as was the response to concanavalin A at 6 weeks. There was no difference in T and B cell numbers, protein concentrations, the presence of autoantibodies and delayed hypersensitivity, and in cortisol, prolactin, growth hormone, and thyroid hormone assays between the bereaved group and the controls. This is the first time severe psychological stress has been shown to produce a measurable abnormality in immune function which is not obviously caused by hormonal changes.