Category: Caregiving

Severity of spinal cord injury in adults is not related to how they rate their health, Wayne State University researchers have found.

In a study of self-rated health (SRH) published this month in the Journal of Spinal Cord Medicine, Cathy Lysack, Ph.D., deputy director of WSU's Institute of Gerontology, along with former Wayne State researcher Katerina Machacova, Ph.D., and Stewart Neufeld, Ph.D., assistant professor in the Institute of Gerontology, evaluated people with spinal cord injuries (SCI) in an effort to better understand the relationship between their self-rated physical ability to perform necessary daily activities and their SRH — the way people perceive their own health.

The study of 140 men and women with SCI found that self-rated physical ability topped injury severity as a determining factor of SRH, which may be surprising to the nondisabled.

"Many nondisabled people would think a person with SCI — confined to a wheelchair, paralyzed, etc. — would have very low ratings of health," said Lysack, an occupational therapist. "But we did not find that. A person with a disability is certainly limited in many ways, but just because they are disabled does not mean they feel their health is poor. This is important because health and disability are not the same thing. You can be living with a disability and still be in very good or even excellent health."

Lysack said the study also is important because the wider scientific literature, most of which comes from studies in aging, indicates SRH is a powerful predictor of other outcomes, including mortality. Prior to this study, few had examined SRH in the context of people with disabilities, so it simply is not known whether this principal holds for people with disabilities too.

The study findings have implications for those who develop instruments to assess physical functioning in older adults and people with disabilities.

"We actually use a lot of the same assessments of physical capacity for those groups as we do for a healthy older person," Lysack said, "and they don't fit particularly well." According to Lysack, assessment tools that are not developed for use with people with disabilities may yield misleading results. There also are many different kinds of disabilities and new instruments will need to be sensitive to that.

Further research also is needed, Lysack said, to determine if a relationship between physical capacities of people is related to SRH in those with spinal cord injury in the same way as it may be for people with Parkinson's disease, a stroke, a hip fracture, vision impairments and many other types of disabilities.

"We simply do not know how the ability to do things is related to SRH in these groups, and how, if it all, SRH predicts other serious outcomes," she said. Ultimately such studies need to be done, and soon, Lysack said, to determine if SRH and self-rated physical ability are a sort of "early warning system" or predictor of future functional decline.

That seems to be true for aging, she said, and if so, SRH and self-rated physical ability become very useful tools in clinical practice.

"If rehabilitation professionals can use these questions to identify people who are at risk for losing their functional independence, then there is a chance to intercede with targeted interventions to prevent or at least forestall the decline," Lysack said.

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Journal Reference:

1. Machacova, Katerina; Lysack, Cathy; Neufeld, Stewart. Self-rated health among persons with spinal cord injury: What is the role of physical ability?Journal of Spinal Cord Medicine, 2011; 34 (3): 265-272(8) DOI: 10.1179/107902610X12883422813660

Massage therapy helps ease chronic low back pain and improve function, according to a randomized controlled trial that the Annals of Internal Medicine will publish in its July 5 issue. The first study to compare structural and relaxation (Swedish) massage, the trial found that both types of massage worked well, with few side effects.

"We found that massage helps people with back pain to function even after six months," said trial leader Daniel C. Cherkin, PhD, a senior investigator at Group Health Research Institute. Better function means they are more able to work, take care of themselves, and be active.

"This is important because chronic back pain is among the most common reasons people see doctors and alternative practitioners, including massage therapists," Dr. Cherkin added. "It's also a common cause of disability, absenteeism, and 'presenteeism,' when people are at work but can't perform well."

The trial enrolled 400 Group Health Cooperative patients who had had low back pain for at least three months. Their pain was "nonspecific," meaning with no identified cause. They were randomly assigned to one of three treatments: structural massage, relaxation massage, or usual care. Usual care was what they would have received anyway, most often medications. The hour-long massage treatments were given weekly for 10 weeks.

At 10 weeks, more than one in three patients who received either type of massage — but only one in 25 patients who got usual care — said their back pain was much better or gone. Also at 10 weeks, a questionnaire showed nearly twice as many massage patients (around two thirds) as usual-care patients (more than one third) were functioning significantly better than at the trial's outset. Patients in the massage groups spent fewer days in bed, were more active, and used less anti-inflammatory medication than did those with usual care.

"As expected with most treatments, the benefits of massage declined over time," Dr. Cherkin said. "But at six months after the trial started, both types of massage were still associated with improved function." After one year, the benefits of massage were no longer significant.

The bottom line: "We found the benefits of massage are about as strong as those reported for other effective treatments: medications, acupuncture, exercise, and yoga," Dr. Cherkin said. "And massage is at least as safe as other treatment options. So people who have persistent back pain may want to consider massage as an option."

Prior studies of massage for back pain had tested only structural forms of massage, not relaxation massage. But relaxation (also called Swedish) massage is the most widely available and is taught in massage schools. It aims to promote a feeling of relaxation throughout the body. By contrast, structural massage involves identifying and focusing on specific pain-related "soft tissues" (like muscles and ligaments). It requires extra training and may be more expensive — but more likely to be covered by health insurance plans — than relaxation massage.

"The massage therapists assumed structural massage would prove more effective than relaxation massage," said Dr. Cherkin's colleague Karen J. Sherman, PhD, MPH, a senior investigator at Group Health Research Institute. "They were surprised when patients in the relaxation group got so much relief from their back pain."

Next steps include figuring out whether the structural and relaxation massages were equally effective for the same — or for different — reasons:

• Structural or relaxation massage, or both, might have specific effects, such as stimulating tissue or calming the central nervous system.
• Either or both might work through "nonspecific effects" that may promote a person's ability to play an active role in their own healing. Possible nonspecific effects include: being touched; spending time in a relaxing environment; receiving care from a therapist who seems caring; getting advice on caring for yourself, such as exercises to do on your own; or becoming more aware of your own body, so you're better able to avoid triggers for your back pain.
• Some combination of specific and nonspecific effects might be at play.

Drs. Cherkin and Sherman's co-authors are Assistant Investigator Andrea J. Cook, PhD, of Group Health Research Institute and the University of Washington; Biostatisticians Robert Wellman, MS, and Eric A. Johnson, MS, Project Manager Janet Erro, RN, MN, and Analyst/Programmer Kristin Delaney, MPH, of Group Health Research Institute; Janet Kahn, PhD, of the University of Vermont School of Medicine in Burlington; and Richard A. Deyo, MD, MPH, of Oregon Health and Science University in Portland, OR.

The National Center for Complementary and Alternative Medicine (NCCAM), part of the National Institutes of Health, funded this study.

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Journal Reference:

1. Daniel C. Cherkin, Karen J. Sherman, Janet Kahn, Robert Wellman, Andrea J. Cook, Eric Johnson, Janet Erro, Kristin Delaney, Richard A. Deyo. A Comparison of the Effects of 2 Types of Massage and Usual Care on Chronic Low Back Pain: A Randomized, Controlled Trial. Annals of Internal Medicine, 2011; 155 (1): 1-9 

Recently the number of genes known to be associated with Alzheimer's disease has increased from four to eight, including the MS4A gene cluster on chromosome 11. New research published in BioMed Central's open access journal Genome Medicine has expanded on this using a genome-wide association study (GWAS) to find a novel location within the MS4A gene cluster which is associated with Alzheimer's disease.

Alzheimer's disease is the most common cause of dementia in the developed world. It irrevocably destroys cells in the brain that are responsible for intellectual ability and memory. Despite continued investigation, the causes of Alzheimer's disease are not yet fully understood but they are thought to be a mixture of genetic and environmental factors. Several studies have used GWAS to search the entire human genome for genes which are mutated in Alzheimer's sufferers in the hope of finding a way to treat or slow down the disease.

A team of researchers across Spain and USA sponsored by non-profit Fundación Alzheimur (Comunidad Autónoma de la Región de Murcia) and Fundació ACE Institut Català de Neurociències Aplicades performed their own GWAS study using patients with Alzheimer's disease, and non-affected controls, from Spain and then combined their results with four public GWAS data sets. Dr Agustín Ruiz said, "Combining these data sets allowed us to look more accurately at small genetic defects. Using this technique we were able to confirm the presence of mutations (SNP) known to be associated with Alzheimer's disease, including those within the MS4A cluster, and we also found a novel site."

Dr Ruiz continued, "Several of the 16 genes within the MS4A cluster are implicated in the activities of the immune system and are probably involved in allergies and autoimmune disease. MS4A2 in particular has been linked to aspirin-intolerant asthma. Our research provides new evidence for a role of the immune system in the progression of Alzheimer's disease."

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Journal Reference:

1. Carmen Antunez, Mercè Boada, Antonio Gonzalez-Perez, Javier Gayan, Reposo Ramirez-Lorca, Juan Marín, Isabel Hernandez, Concha Moreno-Rey, Francisco J Morón, Jesús López-Arrieta, Ana Mauleón, Maitée Rosende Roca, Fuensanta Noguera-Perea, Agustina Legaz-García, Laura Vivancos-Moreau, Juan Velasco, José M Carrasco, Montserrat Alegret, Martirio Antequera-torres, Salvadora Manzanares, Alejandro Romo, Irene Blanca, Susana Ruiz, Anna Espinosa, Sandra Castaño, Blanca García, Begoña Martínez-Herrada, Georgina Vinyes, Asunción Lafuente, James T Becker, José J Galán, Manuel Serrano-Ríos, Lluis Tárraga, María E Sáez, Enrique Vázquez, Oscar L López, Luis M Real and Agustín Ruiz. The membrane-spanning 4-domains, subfamily A (MS4A) gene cluster contains a common variant associated with Alzheimer's disease. Genome Medicine, 2011

It likely comes as no surprise that low back pain is the most common form of chronic pain among adults. Lesser known is the fact that those withchronic pain also experience cognitive impairments and reduced gray matter in parts of the brain associated with pain processing and the emotional components of pain, like depression and anxiety.

In a longitudinal study published this week in the Journal of Neuroscience, a group of pain researchers from McGill University and the McGill University Health Centre (MUHC) posed a fundamental question: If you can alleviate chronic low back pain, can you reverse these changes in the brain?

The answer is yes, they say.

The team began by recruiting, through the Orthopedic Spine Clinic and the Alan Edwards Pain Management Unit at the MUHC, patients who have had low back pain for more than six months and who planned on undergoing treatment — either spinal injections or spinal surgery — to alleviate their pain. MRI scans were conducted on each subject before and six months after their procedures. The scans measured the cortical thickness of the brain and brain activity when the subjects where asked to perform a simple cognitive task.

"When they came back in, we wanted to know whether their pain had lessened and whether their daily lives had improved," said the study's senior author, Laura S. Stone from McGill's Alan Edwards Centre for Research on Pain. "We wanted to see if any of the pain-related abnormalities found initially in the brain had at least slowed down or been partially reversed."

Not only did the team observe recovery in the anatomical function of the brain, but also in its ability to function. After the subjects were treated, researchers found increased cortical thickness in specific areas of the brain that were related to both pain reduction and physical disability. And the abnormal brain activity observed initially during an attention-demanding cognitive task was found to have normalized after treatment.

While more research would be needed to confirm whether chronic pain actually causes these changes in the brain, Stone hypothesizes that chronic low back pain, at the very least, maintains these differences.

"If you can make the pain go away with effective treatment," she added, "you can reverse these abnormal changes in the brain."

Other contributing researchers on this study include David A. Seminowicz (formerly of McGill, currently at the University of Maryland); Timothy H. Wideman (McGill); Lina Naso (McGill); Zeinab Hatami-Khoroushahi (McGill); Summaya Fallatah (McGill); Mark A. Ware (McGill/MUHC); Peter Jarzem (McGill/MUHC); M. Catherine Bushnell (McGill); Yoram Shir (McGill/MUHC); and Jean A. Ouellet (McGill/MUHC.)

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Journal Reference:

1. D. A. Seminowicz, T. H. Wideman, L. Naso, Z. Hatami-Khoroushahi, S. Fallatah, M. A. Ware, P. Jarzem, M. C. Bushnell, Y. Shir, J. A. Ouellet, L. S. Stone. Effective Treatment of Chronic Low Back Pain in Humans Reverses Abnormal Brain Anatomy and Function. Journal of Neuroscience, 2011; 31 (20): 7540 DOI: 10.1523/JNEUROSCI.5280-10.2011

— Using age alone to identify those at risk of heart disease or stroke could replace current screening methods without diminishing effectiveness, according to a groundbreaking study published in the open access journal PLoS ONE.

Existing screening methods which include measuring cholesterol and blood pressure are expensive and time consuming. The authors of the new study from Barts and The London Medical School say that this finding could save thousands of lives by making it easier for more people to have access to preventive treatment.

The new study compared screening using age alone with screening using age and multiple risk factors, measured via blood tests and medical examination. The authors used existing data to estimate the effects of the two screening approaches on a modelled population of 500,000 people.

Age screening alone using a cut off of 55 years had an 84 per cent detection rate and a 24 per cent false-positive rate. This is equivalent to correctly identifying 84 per cent of all the people in a population who will have a stroke or heart attack, while incorrectly identifying 24 per cent who will not. Current screening methods can achieve the same 84 per cent detection rate with a false-positive rate that is only slightly less — 21 per cent.

Professor Sir Nicholas Wald is lead author and Director of the Wolfson Institute at Barts and The London School of Medicine and Dentistry, part of Queen Mary, University of London. He said: "This study shows that age screening for future cardiovascular disease is simpler than current assessments, with a similar screening performance and cost effectiveness. It also avoids the need for blood tests and medical examinations.

With age screening all individuals above a specified age would be offered preventive treatment. Everyone would benefit because, for blood pressure and cholesterol, the lower the better. The policy of selecting people above a certain age is, in effect, selecting people at high risk. It recognises that age is by far the most important determinant of that risk with other factors adding little extra prognostic information.

"Prevention is better than measurement," Professor Wald added. "Identifying people at high risk of cardiovascular disease needs to be greatly simplified, enabling people to obtain easy access to preventive treatment from nurses and pharmacists as well as from doctors.

"Offering appropriate preventive treatment to everyone aged 55 and over in England and Wales could prevent over 100,000 heart attacks and strokes every year."

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Journal Reference:

1. Nicholas J. Wald, Mark Simmonds, Joan K. Morris. Screening for Future Cardiovascular Disease Using Age Alone Compared with Multiple Risk Factors and Age. PLoS ONE, 2011; 6 (5): e18742 DOI: 10.1371/journal.pone.0018742

— In Parkinson's disease, the human body generates antibodies to combat the amyloid-producing protein alpha synuclein early in the course of the disease. A simple blood test that measures these antibodies can facilitate early diagnosis of the disorder, writes Ludmilla Morozova-Roche and her associates at Umeå University in Sweden in the latest issue of the journal PLoS One.

The need for diagnostic biomarkers for degenerative disorders affecting the nervous system, such as Parkinson's and Alzheimer's, is great and acute. Early diagnosis of such diseases would enable treatment at a stage when they are most responsive to intervention, during the period when the greatest number of nerve cells are being damaged or dying. Research is underway around the world to develop substances that can affect the course of the disease.

What many neurodegenerative diseases have in common is that they are caused by proteins that lump together into so-called amyloid. Ludmilla Morozova-Roche's research team has found endogenous antibodies against the most important amyloid-producing protein in Parkinson's disease, antibodies that could function as a diagnostic marker for the disease. Monitoring the levels of endogenous antibodies in patients' blood serum is simple and requires nothing more than a blood sample. This can become a method in clinical practice.

Ludmilla Morozova-Roche's research is conducted in collaboration with Lars Forsgren, professor of neurology at Umeå University and chief physician at Norrlands University Hospital in Umeå, who is directing the research program on early diagnostics and monitoring of Parkinson's patients. The findings indicate that autoimmunity may play a protective role in Parkinson's disease. Immune reactions to the disease's most significant amyloid-producing protein alpha synuclein may be of value in developing treatment strategies such as vaccination with amyloid antigens and antibodies, especially in the early stages of the disorder.

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Journal Reference:

1. Kiran Yanamandra, Marina A. Gruden, Vida Casaite, Rolandas Meskys, Lars Forsgren, Ludmilla A. Morozova-Roche. α-Synuclein Reactive Antibodies as Diagnostic Biomarkers in Blood Sera of Parkinson's Disease Patients. PLoS ONE, 2011; 6 (4): e18513 DOI: 10.1371/journal.pone.0018513

 Group appointments where doctors see several people for a longer time may be feasible for Parkinson's disease, according to a new study published in the April 27, 2011, online issue of Neurology®, the medical journal of the American Academy of Neurology (AAN).

Group visits have shown benefits for people with other chronic conditions, but have not been evaluated for people with Parkinson's disease. Group visits can allow patients more time with their doctor than they might have with individual appointments and more time for doctors to provide education on managing the disease.

The randomized, controlled study compared people receiving their normal care from a physician to people receiving care through group visits with their regular physician over one year. Caregivers were also included in the study.

Those receiving their usual care had 30-minute appointments with their physicians every three to six months. The group visits lasted 90 minutes and were held every three months. They included introductions, updates from patients, and an educational session on a topic chosen by the participants. Time was allotted for questions from patients or caregivers and individual 10-minute appointments with the physician were scheduled for before or after the group visit for individual concerns.

Of the 30 study participants, 27, or 90 percent, completed the study, along with 25, or 93 percent of the 27 participating caregivers. At the end of the study, there was no difference between those receiving usual care and those participating in the group visits in how they rated their overall quality of life.

Participants were asked whether they preferred the group visits or usual care at the end of the study. Of the 14 receiving group visits who responded, eight preferred the group setting, five preferred usual care, and one was indifferent. Of those receiving usual care who responded, five preferred group visits, six preferred usual care, and three were undecided. None of the participants reported any confidentiality issues.

Study author E. Ray Dorsey, MD, MBA, of Johns Hopkins University School of Medicine in Baltimore, MD, and a member of the American Academy of Neurology, said group visits have the potential to address limitations of support groups and traditional doctor visits.

"While both support groups and traditional visits have clear benefits, a survey of people with Parkinson's showed that they desire a credible group leader for their support groups and more information for them and their caregivers about their disease," he said. "Group visits can address these limitations. They also give physicians the opportunity to observe their patients for a longer period of time and appreciate disease characteristics such as fluctuations in their symptoms and daytime sleepiness that may not readily be appreciated during a routine 20- to 30-minute office visit."

Dorsey noted that group visits may pose logistical issues, such as the need for a large room and scheduling difficulties. He said that the risk that the lack of a one-on-one examination could lead physicians to miss subtle problems could be resolved by using a hybrid model alternating group and individual appointments.

Stephen G. Reich, MD, of the University of Maryland School of Medicine in Baltimore, MD, who was not involved in the study and wrote an accompanying editorial, noted that the study participants all had mild to moderate Parkinson's disease, suggesting that people with more advanced disease may be less willing to forgo individual appointments.

The study was supported by a grant from the National Parkinson Foundation.

Cholesterol-lowering drugs known as statins may help clot-busting drugs treat strokes, according to researchers at Washington University School of Medicine in St. Louis.

The research involved 31 patients with ischemic stroke, a disorder when a clot blocks blood flow to part of the brain. In 12 patients who were already taking statins to control their cholesterol, blood flow returned to the blocked areas of the brain more completely and quickly.

"We've known that patients on statins have better stroke outcomes, but the data in this study suggest a new reason why: Statins may help improve blood flow to brain regions at risk of dying during ischemic stroke," says senior author Jin-Moo Lee, MD, PhD, director of the cerebrovascular disease section in the Department of Neurology. "If that turns out to be the case, we may want to consider adding statins to the clot-busting drugs we normally give to acute stroke patients."

The results appear online in the journal Stroke.

The stroke team first established that patients were having an ischemic stroke and treated them with a clot-busting drug. An MRI scan was performed during treatment with the clot-busting drug and again three hours later to assess the restoration of blood flow to blocked areas.

"To our knowledge, this is the first time someone has looked at the effects of statins on restoration of blood flow using brain tissue-based measurements instead of looking at the opening of blood vessels," says lead author Andria Ford, MD, assistant professor of neurology. "It's harder to do, but we feel it gives us more accurate measurements."

Within three hours after treatment, blood flow restoration in the 12 patients already on statins averaged 50 percent. In the 19 patients not taking statins, though, the average was 13 percent.

Doctors tested the patients on arrival to the hospital and at one month after their strokes using the National Institutes of Health Stroke Scale, an assessment that evaluates a variety of functions including speech, movement, attention and sensation. Patients taking statins had greater improvements in their scores at the one-month test, an indicator that their strokes were less damaging or that they were recovering more quickly.

Statins already are recognized for having beneficial effects beyond lowering cholesterol, Lee says. These include beneficial effects on the health of cells that line blood vessels and increased production of nitric oxide, a compound that dilates blood vessels. He says a larger study is needed to confirm that statins improve restoration of blood flow after stroke, leading to less disability.

"We don't know yet if this potential effect depends on taking statins every day, or if giving statins to patients when they have a stroke can have similar benefits," Lee says. "Based on our data, though, these questions are worth looking into."

Funding from the National Institutes of Health, the National Center for Research Resources and the NIH Roadmap for Medical Research supported this research.

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Journal Reference:

1. A. L. Ford, H. An, G. D'Angelo, R. Ponisio, P. Bushard, K. D. Vo, W. J. Powers, W. Lin, J.-M. Lee. Preexisting Statin Use Is Associated With Greater Reperfusion in Hyperacute Ischemic Stroke. Stroke, 2011; DOI: 10.1161/STROKEAHA.110.600957

— Improved management of chronic pain can significantly reduce disability in older adults, according to the latest issue of the What's Hot newsletter from The Gerontological Society of America (GSA).

Based largely on presentation highlights from GSA's 63rd Annual Scientific Meeting in November 2010, the current What's Hot examines the impact of pain in older adults, strategies for managing pain and preserving function, and methods to improve the assessment and management of pain for residents in long-term care facilities, including those who have dementia. Support for this publication was provided by McNeil Consumer Healthcare.

"Under-treatment of chronic pain in older adults is common, contributing to unnecessary suffering," said Deborah Dillon McDonald, RN, PhD, of the University of Connecticut School of Nursing, who served as an advisor for the issue. "Older adults and practitioners need to work together to find optimal multi-modal pain management plans that reduce pain and avoid adverse events."

The newsletter points out that pain is a signal that something is wrong, and that reports of pain should not be dismissed simply because the patient is older. Furthermore, the issue demonstrates that chronic musculoskeletal pain is associated with numerous problems such as increased disability and sleep difficulty in older people. The research and national initiatives presented therein underscore the importance of good pain management in older adults and explore strategies for optimizing patient well-being.

Among the most successful methods for pain treatment are physical activity, pain protocol interventions, and medication use. Additional topics raised in the newsletter focus on ongoing activities to support safe selection and use of analgesics (including appropriate acetaminophen dosage), which is important to communicate to multiple stakeholders, including patients, caregivers, health care providers, policymakers, and researchers.

Public relations professionals constantly look for ways to most effectively promote their messages to the media. Sun-A Park, a researcher at the University of Missouri School of Journalism surveyed more than 300 health journalists and found that those who cover strokes and stroke prevention tend to hold negative views of corporate pharmacy media relations, while those who regularly read medical journals tend to cover more stories based on corporate press releases.

Park says one key factor influencing journalists' attitudes concerning corporate media press releases is the specific health topics they cover.

"Not many public relations campaigns are devoted to stroke and stroke prevention, which would help explain the low public recognition of strokes," Park said. "So health journalists who write about strokes are not accustomed to receiving public relations materials and thus are uncomfortable with the topic."

Park also found that the more frequently health journalists read other newspapers and medical journals, the more open they are to covering stories based on press releases. Park says if journalists already depend on other media sources to help decide what is newsworthy, this habit could extend to public relations press releases as well. She also thinks deadline pressure can play a role.

"Journalists are often under deadline pressure; and if they routinely read medical journals for story ideas, they develop a willingness to use sources that help simplify complex and difficult health topics for a broad audience," Park said. "Thus, health journalists who read medical journals are more receptive to using corporate pharmacy press releases in order to meet deadlines and help general news audiences to better understand the information."

Park's study also revealed that health journalists who serve a metropolitan audience rather than those who serve national or small community audiences, are more likely to have positive attitudes toward corporate pharmacy media relations. Park recommends that corporate pharmacy public relations professionals target these specific journalists with their press releases in order to be most efficient and effective with their efforts.

This study was conducted by the Health Communication Research Center in the University of Missouri School of Journalism. It was published in PRism, a public relations journal.