Factors associated with referral to physiotherapists for adult patients consulting for musculoskeletal disorders in primary care; an ancillary study to ECOGEN.

BACKGROUND: Musculoskeletal disorders (MSD) are multifactorial requiring multidisciplinary treatment including physiotherapy. General practitioners (GP) have a central role in managing MSDs and mostly solicit physiotherapists accounting for 76.1% of physiotherapy referrals in France. Patient, physician, and contextual factors, including healthcare accessibility, can influence physiotherapy referral rates. OBJECTIVE: To identify patient, physician, and contextual factors associated with physiotherapy referral in adult patients with MSDs in general practice. METHODS: This study is based on the 2011/2012 French cross-sectional ECOGEN study. Analyses included working-age patients consulting their GP for any MSD. Physiotherapy referral was assessed initially, then adjusted multilevel logistic model analysis of patient, physician, geographical area-related factors associated with these referrals was performed. RESULTS: Among the 2305 patients included, 456 (19.8%) were referred to a physiotherapist. Following multilevel multivariate analyses, physiotherapist referral was more frequent for female patients (OR 1.28; 95% CI [1.03, 1.59]) with spinal (OR 1.47; 95% CI [1.18, 1.83]) and upper limb disorders (OR 1.66; 95% CI [1.20, 2.29]), and less frequent for patients ≥ 50 years (OR 0.69; 95% CI [0.52, 0.91]), living in deprived geographical areas (OR 0.60; 95% CI [0.40, 0.90]). GPs referred to a physiotherapist less frequently if they were ≥ 50 years (OR 0.50; 95% CI [0.39, 0.63]), had a high number of annual consultations, or were practicing in semi-urban area in a multidisciplinary team. CONCLUSION: This multilevel analysis identifies factors associated with physiotherapy referral for patients with MSDs, including living in deprived geographical areas. This constitutes an original contribution towards addressing healthcare disparities.

Evolution of psychosocial factors at work in a French region.

BACKGROUND: Psychosocial factors at work (PFW) can be defined as all non-physicochemical occupational risks. Several epidemiological models have been proposed to measure PFW, but one of the most widely used is Karasek's model. AIMS: To determine whether psychosocial factors, evaluated by Karasek's questionnaire, had increased in a cohort of workers. METHODS: A random sample of workers in the Pays de la Loire region of France, who could be considered representative of the region's population of salaried workers, filled in a self-administered questionnaire, including Karasek's self-administered questionnaire, in 2002-05 and 2007-09. Karasek's questionnaire can be used to study three psychosocial dimensions (psychological demand, decision latitude and social support in the workplace) in workers in order to define two high-risk situations for their health: 'Job Strain' and 'Iso Strain'. Changes in job strain and iso strain among workers were studied according to the workers' sociodemographic characteristics and their working conditions. RESULTS: In this sample of 2049 workers, the proportion with iso strain increased between the two periods from 12 to 16%, P < 0.001, mainly among manual workers. Deterioration of Karasek indicators was mainly explained by an increase of the 'low social support' dimension (38 versus 49%, P < 0.001). Working conditions such as temporary employment of colleagues and high perceived physical exertion were associated with higher PFW. CONCLUSIONS: This study, based on a quantitative and collective model, showed deterioration of working team environments and increased risk for individual mental health in this cohort of French workers in recent years.

Carpal tunnel syndrome and computer exposure at work in two large complementary cohorts.

OBJECTIVES: The boom in computer use and concurrent high rates in musculoskeletal complaints and carpal tunnel syndrome (CTS) among users have led to a controversy about a possible link. Most studies have used cross-sectional designs and shown no association. The present study used longitudinal data from two large complementary cohorts to evaluate a possible relationship between CTS and the performance of computer work. SETTINGS AND PARTICIPANTS: The Cosali cohort is a representative sample of a French working population that evaluated CTS using standardised clinical examinations and assessed self-reported computer use. The PrediCTS cohort study enrolled newly hired clerical, service and construction workers in several industries in the USA, evaluated CTS using symptoms and nerve conduction studies (NCS), and estimated exposures to computer work using a job exposure matrix. PRIMARY AND SECONDARY OUTCOME MEASURES: During a follow-up of 3-5 years, the association between new cases of CTS and computer work was calculated using logistic regression models adjusting for sex, age, obesity and relevant associated disorders. RESULTS: In the Cosali study, 1551 workers (41.8%) completed follow-up physical examinations; 36 (2.3%) participants were diagnosed with CTS. In the PrediCTS study, 711 workers (64.2%) completed follow-up evaluations, whereas 31 (4.3%) had new cases of CTS. The adjusted OR for the group with the highest exposure to computer use was 0.39 (0.17; 0.89) in the Cosali cohort and 0.16 (0.05; 0.59) in the PrediCTS cohort. CONCLUSIONS: Data from two large cohorts in two different countries showed no association between computer work and new cases of CTS among workers in diverse jobs with varying job exposures. CTS is far more common among workers in non-computer related jobs; prevention efforts and work-related compensation programmes should focus on workers performing forceful hand exertion.

Prevalence of thoracic spine pain in a surveillance network.

BACKGROUND: Back pain has long been identified as a major occupational health issue, but there are few prevalence studies on thoracic spine pain (TSP). The epidemiological surveillance of musculoskeletal disorders implemented in 2002 by the French Institute for Public Health Surveillance in the Pays de la Loire region provided the opportunity to study the prevalence of TSP in a large, representative sample of workers. AIMS: To assess the prevalence of TSP across a week in a regional workforce according to age, occupational category and industry sector in men and women separately. METHODS: A random sample of workers aged 20-59 years, representative of the regional workforce, was constituted between 2002 and 2005. Medical and occupational data were gathered by questionnaire. RESULTS: The sample consisted of 3710 workers (58% men). The prevalence of TSP was higher in women (17%) than in men (9%). Lower grade male white-collar workers were more likely to report TSP (17%) than male workers in other occupational categories, whereas upper grade female white-collar and professional workers were more likely to report TSP. No significant difference in the prevalence of TSP was noted in either men or women according to industry sector. CONCLUSIONS: Although TSP is less frequent than low back and neck pain, the results of this study indicate that 1 in 10 men and 1 in 5 women suffer from TSP.

Mechanisms of action of midazolam on expression of contextual fear in rats.

BACKGROUND: Midazolam may suppress conditioned fear after an aversive event by disrupting the memory trace formed during conditioning, by altering the emotional part of the aversive event, or by the combination of both effects. The purpose of the present study was to determine whether affective-related processes contribute to the amnesic-like effects of midazolam on aversive events. METHODS: The effects of acute administration of low doses of midazolam (0.37-3 mg kg(-1)) on fear conditioning (association between a neutral context and an aversive stimulus) and on innate anxiety in fearful surroundings were examined in rats. The effect of midazolam on the deleterious consequences of pre-exposure to the context (a non-aversive event) for subsequent fear conditioning was then compared with its effect on fear conditioning. The role of midazolam as an affective context was assessed by performing the testing phase under midazolam. Possible locomotor impairment or long-term effects of midazolam were controlled in additional experiments. RESULTS: Midazolam reduced both contextual fear conditioning and spontaneous fear. The deleterious effect of midazolam on pre-exposure to the context was of the same magnitude as its effect on the acquisition phase of fear conditioning. The effects of midazolam on both pre-exposure to the context and fear conditioning were unchanged when rats received a second injection of midazolam before the retention phase. CONCLUSIONS: Low doses of midazolam that do not impair locomotion suppress conditioned fear to the context by acting on memory processes rather than on affective or anxiolytic processes.

Synthesis of C-X-C and C-C chemokines by human peritoneal fibroblasts: induction by macrophage-derived cytokines.

Leukocyte accumulation during peritonitis is believed to be controlled by chemotactic factors released by resident peritoneal macrophages or mesothelial cells. Recent data indicate, however, that in many tissues fibroblasts play a key role in mediating leukocyte recruitment. We have therefore examined human peritoneal fibroblasts (HPFBs) for the expression and regulation of C-X-C and C-C chemokines. Quiescent HPFBs secreted monocyte chemoattractant protein (MCP)-1 and interleukin (IL)-8 constitutively. This release could be dose-dependently augmented with the pro-inflammatory cytokines IL-1beta and tumor necrosis factor-alpha. Stimulated IL-8 production reached a plateau within 48 hours while MCP-1 continued to accumulate throughout 96 hours. Induction of IL-8 and MCP-1 synthesis by HPFBs was also triggered by peritoneal macrophage-conditioned medium. This effect was partly related to the presence of IL-1beta as demonstrated by IL-1 receptor antagonist inhibition. Pretreatment of HPFBs with actinomycin D or puromycin dose-dependently reduced cytokine-stimulated IL-8 and MCP-1 secretion, which suggested de novo chemokine synthesis. Indeed, exposure of HPFBs to IL-1beta and tumor necrosis factor-alpha produced a significant up-regulation of IL-8 and MCP-1 mRNA. This effect was associated with the rapid induction of nuclear factor-kappaB binding activity mediated through p65 and p50 subunits, and with a transient increase in the mRNA expression for RelB and inhibitory protein kappaB-alpha proteins. These data indicate that peritoneal fibroblasts are capable of generating large quantities of chemokines under a tight control of nuclear factor-kappaB/Rel transcription factors. Thus, peritoneal fibroblast-derived chemokines may contribute to the intraperitoneal recruitment of leukocytes during peritonitis.

Relative validity of contextual and discrete cues.

Contextual conditioning during relative validity training was explored in 3 experiments that used an appetitive Pavlovian conditioning preparation with rats. Magazine entries were the conditioned response. In Experiment 1, true-discrimination (TD: AX+, BX-) training generated weaker conditioning of X than did pseudodiscrimination (PD: AX+/-, BX+/-) training. The context showed a similar relative validity effect. Also, both PD training and simple partial reinforcement (X+/-) reduced contextual conditioning more than did unsignaled food, a demonstration of relative validity using partial reinforcement. Experiments 2 and 3 used within-subject and between-subjects designs, respectively, and showed that relative validity was determined by the summation of differences in conditioning to both the common element (X) and the context. Our results are consistent with an attentional model or with a computational comparator model but not with the Rescorla-Wagner (R. A. Rescorla & A. R. Wagner, 1972) model.

Relative validity effects with either one or two more valid cues in Pavlovian and instrumental conditioning.

Two experiments investigated the relative validity effect with either 1 or 2 continuously reinforced cues in Wistar rats using appetitive Pavlovian and instrumental preparations. Discrimination training involved 3 compound cues containing a common element (1AX: 1BX: 2CX). In the first true-discrimination group (TD-1), CX was followed by food, but AX and BX were not. In the second true-discrimination group (TD-2), AX and BX but not CX were followed by food. In the third, pseudodiscrimination group (PD), food followed 50% of each compound. Compared with the PD group, there were lower levels of responding to X in Groups TD-1 and TD-2, which did not differ. That is, both TD treatments showed equivalent relative validity effects. There was evidence for a relative validity effect on the context. The Rescorla-Wagner model incorrectly predicts a smaller relative validity effect after the TD-2 than the TD-1 treatment. Comparator theory predicts these results.

Differential effect of free intake versus oral perfusion of sucrose in conditioned taste aversion in rats.

Five experiments were designed to investigate LiCl-induced conditioned taste aversion (CTA) obtained in rats whether after free intake of a sucrose solution (active mode) or after forced administration through an intraoral cannula (passive mode). It was found in Experiment 1 that actively conditioned rats showed a slower extinction rate as revealed by repeated two-bottle tests (active testing) as opposed to passively conditioned ones. As these rats underwent a mode change between conditioning and testing, the differential extinction rate might have arisen from this change inducing a generalization decrement effect or acting as a contextual shift. In Experiment 2, no evidence for any generalization decrement was found. The possibility that the mode of sucrose delivery could have contextual properties in CTA through a "renewal test" after extinction and a latent inhibition experiment was further tested in Experiments 3 and 4. When active testing followed passive extinction, a CTA was afresh obtained in rats actively conditioned in active conditions. Latent inhibition was attenuated in rats preexposed in passive conditions and conditioned in active conditions (i.e., when a shift in the drinking mode occurred between preexposure and conditioning). In Experiment 5, intraoral perfusion was used in both groups. The active subjects had to nose poke for intraoral administration of sucrose. The yoked control passive subjects received simultaneously the same amount of sucrose. The levels of CTA differed also from the actively to the passively conditioned subjects. Results are discussed in terms of free intake activity acting as a contextual modulator of CTA.

A neurotoxic lesion of serotonergic neurones using 5,7-dihydroxytryptamine does not disrupt latent inhibition in paradigms sensitive to low doses of amphetamine.

Testing the effects of low doses of d-amphetamine on latent inhibition (LI) in two different conditioning paradigms, passive avoidance and conditioned taste aversion, provided evidence of their pharmacological equivalence. For passive avoidance, LI was expressed by the decreased latency to enter a shock compartment in preexposed rats placed 5 min in the compartment during 3 consecutive days before conditioning. In the conditioned taste aversion paradigm, a group of rats was preexposed to a solution of sucrose also for 3 consecutive days prior to the establishment of an association between sucrose and sickness elicited by an injection of LiCl. On the following day, the preexposed rats drunk more sucrose when allowed to choose between one tube containing water and an other containing sucrose. In both paradigms, 0.25 mg/kg d-amphetamine, injected daily on the 3 preexposure days and on the conditioning day, decreased LI. A dose of 0.5 mg/kg suppressed LI in the passive avoidance paradigm. The effect of a serotonergic lesion induced by i.c.v. injection of 5,7-dihydroxytryptamine (5,7-DHT) was evaluated in the same paradigms. The lesion procedure that lowered hippocampal serotonin and 5 HIAA levels by more than 80% did not affect LI. Taken together, the present results lessens the hypothesis that LI is prone to an opposing influence of the two monoaminergic systems considered in this work.