Workshop 1 (synthesis): systems for sustainable urban water services.

The systems approach is absolutely essential to secure sustainability in urban water services. The financing dimension is critical; fragmented institutions are a great barrier, hindering a systems approach; recycling of water and nutrients is vital for food production and livelihood improvements; effective knowledge transfer about innovative approaches to sanitation is essential to share success stories and failures.

Connective tissue massage in the treatment of fibromyalgia.

The aim of this study was to investigate the effect of connective tissue massage in the treatment of individuals with fibromyalgia. The results of this random study of 48 individuals diagnosed with fibromyalgia (23 in the treatment group and 25 in the reference group) show that a series of 15 treatments with connective tissue massage conveys a pain relieving effect of 37%, reduces depression and the use of analgesics, and positively effects quality of life. The treatment effects appeared gradually during the 10-week treatment period. Three months after the treatment period about 30% of the pain relieving effect was gone, and 6 months after the treatment period pain was back to about 90% of the basic value. As long as there is a lack of effective medical treatment for individuals with fibromyalgia, they ought to be offered treatments with connective tissue massage. However, further studies are needed in the mechanisms behind the treatment effects. Copyright 1999 European Federation of Chapters of the International Association for the Study of Pain.

A longitudinal study of pain: reported pain from middle age to old age.

OBJECTIVE: Describe patterns of pain reporting over a span of 24 years. DESIGN: Individuals were interviewed on four occasions (1968, 1974, 1981, 1992). PARTICIPANTS: Representative sample (n = 321) of the Swedish population aged 53-63 at baseline. MEASURES: Self-reported pain in the chest, abdomen, and musculoskeletal system (back or hips, shoulders, hands, elbows, legs, or knees). RESULTS: Less than 1% reported chest or abdominal pain on all four occasions. Whereas 21.8% of the sample reported musculoskeletal pain on all four occasions. More than half of the sample reported some kind of pain on three or four occasions. Women reported more severe and more persistent pain compared with men. There were more people who developed pain during the 24-year period than there were who became pain free. An increase in pain was equally common for chest and musculoskeletal pain, but a decrease in pain was much more common for musculoskeletal pain than chest pain. CONCLUSIONS: Cross-sectional studies have shown differing age patterns in pain. This longitudinal study demonstrates different patterns for men and women and for different pain localities.

The incidence of back pain and headache among Swedish school children.

Musculoskeletal pain is exceedingly common in young adults. With the aim of studying these symptoms in schoolchildren, a questionnaire survey was carried out among children 8, 11, 13 and 17 years old. The prevalence of back pain and headaches in 1,245 schoolchildren was studied. Twenty-nine per cent of the students reported back pain and 48% headache. In all age groups studied, both back pain and headaches were more common among girls than boys. Girls also reported more frequent symptoms than boys. In a longitudinal study 471 schoolchildren were asked a second time 2 years later. Nine per cent reported back pain and 30% headache in both surveys. Five per cent reported both back pain and headache on both occasions. Despite the reported symptoms most of the pupils did not report health problems. However, pupils with reported pain on both occasions may constitute a risk group for future chronic pain. There were statistically significant relationships between social, psychological and emotional factors and reported symptoms. No relationship between physical factors and reported symptoms were noted. The observed relationships are not proof of causal relations but did indicate areas of problems which make interventions targeting pupils at risk an appropriate measure.

The validity of a pain questionnaire for postal surveys.

A postal survey aimed at studying the prevalence of chronic pain and the need for care because of pain was carried out in a representative sample of a Swedish population. A random sample of the study population has been interviewed and assessed clinically to determine whether a questionnaire method gives the same results as clinical assessment. The agreement between estimates based on the questionnaire and those based on the clinical assessments varied depending on the questions used. By creating questions more independent of language habits and values, it was shown that it is possible to get better agreement between different descriptions. The best agreement was shown when answers to questions regarding different dimensions of pain were combined in a model for selecting individuals with more serious pain problems.

Selecting patients for pain treatment: applying a model to epidemiological data.

In a postal survey, 1,009 randomly chosen individuals, aged 18-84, were asked about their pain problems. The pain prevalence depended on the kind of questions and definitions used, but prevalence was high overall. In the present study, a model for selecting individuals in need of care was tested. Fifteen percent of individuals were defined as having considerable pain and 25% as having moderate pain. At least 12% of the population was calculated as having sufficient pain problems to need some kind of care. This high figure indicates that the establishment of special treatment facilities can never be sufficient to meet the total demand for care due to pain.

The use of common pain experiences in designing a pain intensity scale for epidemiological purposes.

The planning of services for the treatment of chronic pain does not seem to be based on adequate information. Although some epidemiological studies exist already, there is a need for more epidemiological knowledge. We have tried to develop a mail questionnaire which may, to some extent, separate pain sensory intensity from pain affect and behaviour. In this paper we refer to the development and testing of a pain sensory intensity scale based on common pain experience. 155 subjects classified the intensity of 15 common pain states. The classifications were then compared. The results indicate that there are pain states which many people have experienced and which they are able to rank according to pain intensity. The pain sensory intensity scale we based on five of these pain experiences or groups of pain experience.

Priority setting with regard to placement on waiting list to a pain clinic. The feasibility of a delegated ranking procedure.

Short waiting periods for all patients referred to a pain clinic is desirable but ordinarily not possible. In a questionnaire, 25% of the Swedish anaesthetic pain clinics reported a waiting list exceeding 6 months. The long waiting-time shows that some kind of priority setting is necessary. The aim of the present investigation was to study the feasibility of a rational priority setting based on a ranking procedure. Secretary and nurse priority ranked patients according to a system utilizing the physician's referral and a questionnaire completed by the patient. These priority ratings were compared to the final ranking by the doctor which was done after an interview without access to the questionnaire. The results of the present investigation show that the secretary as well as two nurses generally 'overestimated' the patients' pain problems compared with the priority made by the doctor. However, 12 out of 142 patients' problems were 'underestimated' but this was deemed to increase risk in only one case. The possible risks with a delegated ranking procedure have, however, to be judged against the disadvantages of no priority setting at all and the advantages of a rational use of staff members. This experiment has indicated the feasibility of a delegated ranking procedure.

Are there long lasting effects on migraine headache after one series of acupuncture treatments?

The long term effect of one series of acupuncture treatments on migraine headache was investigated. Twenty-five patients (20 women, 5 men) with a mean migraine history of 22 years and a stable, severe migraine (mean frequency 8 days/28 days) completed the study, out of 30 originally enrolled. The patients recorded the presence, severity and duration of headache as well as drug consumption during three 12 weeks long periods: one pretreatment period (baseline period = BP), follow up period I (FU I) immediately following the treatment period of 6-8 weeks and follow up period II (FU II) starting the 25th post treatment week. An index for migrainous headache was calculated for each 28 day period (number of days times severity rated 1, 2 or 3). Acupuncture was given close to or in the region of the headache. During FU I and FU II the migraine index had decreased 40% and 39%, respectively, compared to BP (to 10.3 and 10.5 from 17.2), giving a statistical significance with p less than 0.01. The number of days with migraine headache was reduced 35 and 34%, respectively, during FU I and FU II to 5.1 and 5.2 from 8.0 days/28 days during BP. This reduction is significant too with p less than 0.05 and was responsible for almost the whole reduction of the index. Thus the severity of the pain was not much changed. On an individual basis 7 of the 25 patients obtained a very large reduction of migraine headache.(ABSTRACT TRUNCATED AT 250 WORDS)