Archive for the ‘family’ tag
Management of Chronic Pain
Comprehensive treatment for chronic pain must address both physical and psychological aspects.
Pain is a leading reason that people seek medical care. Annually, pain is estimated to burden the U.S. economy with $100 billion in direct costs and $61 billion in productivity losses. These losses, which amount to a mean of 4.6 hours weekly, are largely due to diminished performance at work.1 Perhaps more significant, but more difficult to quantify, is the emotional distress and diminished quality of life that pain inflicts on individuals and their loved ones.
WHAT IS PAIN?
Pain, as defined by the International Association for the Study of Pain is “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.”2 Thus, pain is an experience that comprises a physical sensory component and an affective cognitive component. The physical element involves a nociceptive, neuropathic, or inflammatory stimulus that is transmitted via the spinal cord to the thalamus and then to areas of the cerebral cortex, where it is perceived. Acute pain serves a biological purpose as an alert to potential, immediate, or ongoing injury.
Chronic pain is pathologic, serves no biological purpose, and can result from peripheral sensitization, in which processes (such as changes in gene expression in the dorsal root ganglia) augment the synthesis of various peripheral nociceptors. In turn, inputs to the dorsal horn of the spinal cord are amplified, leading to activation of N-methyl-D-aspartate (NMDA) receptors and subsequent spinal cord hyperexcitability. Destruction of inhibitory interneurons and sprouting of nerve fibers at the level of the dorsal horn also can contribute to central sensitization; in addition, disruption of descending inhibitory neural pathways can trigger central hypersensitivity and chronic pain.3
Chronic pain can persist after an initial injury has healed, or it can result from ongoing pathologic processes. Although specific periods (typically 6 months) often are used to define chronic pain, a more appropriate definition of the condition is simply pain that persists longer than it should. Chronic pain often involves neural activity in specific brain areas that are distinct from those that mediate acute pain; for example, unrelenting back pain is processed by areas that also process negative emotions.4 In addition, chronic pain can have widespread effects on overall brain functioning, thereby causing depression, anxiety, and decision-making difficulties in ways that acute pain does not.
WOMEN AND PAIN
Conditions such as headache, pelvic pain, rheumatoid arthritis, and facial pain are more common in women than in men; accordingly, women are two to three times more likely than men to suffer from chronic pain. Compared with men, women also tend to perceive pain as more severe and to report lower pain thresholds and higher pain ratings in research studies. Such sex differences could be secondary to the influence of hormones, family history, traditional sex roles, cognitive factors, and how the central nervous system processes pain.5
INTERDISCIPLINARY TREATMENT OF CHRONIC PAIN
Comprehensive treatment of chronic pain must address both physical and psychological aspects; thus, interdisciplinary approaches to pain management involve medical management, physical therapy, occupational therapy, biofeedback, vocational and recreational therapy, and psychological counseling.
Rational polypharmacy (evidence-based use of multiple medications) is a cornerstone of medical management of pain syndromes, which can encompass sleep and mood disorders. Treatment options include nonsteroidal anti-inflammatory agents, antiepileptic drugs such as gabapentin (for neuropathic pain), antidepressants, and opioid drugs. Use of chronic opioid therapy has risen substantially, along with concerns about drug abuse and addiction; accordingly, treatment recommendations have been developed by the American Pain Society and the American Academy of Pain Medicine to provide guidance about patient selection, risk factors for abuse, and opioid management plans.6 Chronic opioid treatment is appropriate if analgesia is achieved, adverse side effects do not occur, activities of daily living improve, and aberrant behavior or signs of abuse are not present (sometimes referred to as the four A’s). In addition to documentation of the four A’s, clinicians’ use of opioid contracts with patients, as well as random urine screens, all help to justify prescribing these agents as part of therapy for patients with chronic pain. Other medical strategies involve steroid injections (epidural or delivered directly to affected joints) to treat pain flares, and, when indicated, surgical approaches.
Physical therapy serves to allay the patient’s fear of movement; to teach the difference between “hurt” and “harm” sensations; to increase endurance, range of motion, and tolerance for sitting, standing, and walking; and to improve posture and strength. Occupational therapy addresses body mechanics, pacing, functional mobility and activities of daily living, and ergonomic modifications in the workplace. Biofeedback helps the patient to master diaphragmatic breathing and progressive muscle relaxation with the goals of alleviating muscle tension, reducing physical and emotional distress, and encouraging mindfulness of pain in an effort to divert attention away from it.
Managing pain largely entails attending to its psychological features and their impingement on overall emotional status. Sleep disturbances, anxiety, and depression can be treated with psychotherapy and, when required, pharmacologic agents. Along with medical management, cognitive-behavioral therapy (CBT) is often a mainstay of treatment.7 CBT is based on the theory that thoughts affect feelings and behaviors, which, in turn, influence how one experiences pain. CBT teaches individuals how to identify negative dysfunctional pain-related thoughts and how to replace them with more-adaptive thoughts. Ideally, one learns coping skills that can be applied to daily situations, including pain flares.
A key goal of CBT — indeed, of all the therapies for chronic pain — is to foster the belief that patients have the power to manage their pain by improving their physical abilities and by learning how to control their thoughts, behaviors, and reactions. Having a healthy sense of command of oneself includes being both physically and socially active and integrated. Unremitting pain leads to lower physical activity levels, resulting in diminished function and greater likelihood of depression; maintaining higher activity levels leads to less pain, thereby breaking the cycle.
Maintaining a sense of control is undeniably challenging for women who are in continual pain. Isolation and depression commonly accompany chronic pain conditions, which makes treatment difficult. Women must learn to maintain direction over their own lives and take time to care for themselves while also meeting the challenges of employment, caring for their families, and remaining socially integrated. Being able to do all of this, in addition to handling a debilitating condition, can be demoralizing and exhausting — physically, emotionally, and financially. Likewise, managing chronic pain conditions can be challenging and potentially draining for clinical pain-care teams. The treating clinician has a responsibility not only to educate the patient that her chronic pain is a disease but also to stop ongoing and unnecessary laboratory and radiologic testing after the diagnosis has been made definitively.
CONCLUSION
Collaboration among therapists, psychologists, and other supportive resources is crucial to delivering effective pain treatments. Helping women with chronic pain to take ownership of their conditions and to actively curb physical and emotional aspects will boost their functional mobility, productivity, and quality of life while also shrinking the associated financial burden.
School Based Clinics
The Paediatric School-Based Clinics were established in May of 2007, in response to the ‘Health disparity by Neighbourhood Income” study that was published by the SHR (Dr. Mark Lemstra et al). The clinics are a product of the efforts of the Department of Paediatrics, College of Medicine at the U of S, the Catholic and Public school Divisions and The Saskatoon Tribal Council, in consultation with the Core Neighbourhood communities to provide access to comprehensive paediatric care.
Acknowledging that it is the social determinants of health such as income, literacy, and housing that impact people’s health, we provide care to children in core neighbourhoods, embracing the community paediatrics model which shifts away from one child but to ‘all children in the community, within the context of the family and the community’. We adhere to the principals of cultural competency.
The clinic is collaborative; i.e. seeking to work across sectors such as Education, Social Services, Justice, Law Enforcement etc; as well as integrated, i.e. working alongside teachers, councilors, social workers psychologists, ENT, Child Psychiatry.
The clinics are currently based out of St. Mary’s Elementary School (Mon/ Tues/ Wed); as well as W.P. Bate Elementary school on Thursday afternoon. It is staffed by 2 Paediatrcians from the department of paediatrics. Appointments are not mandatory, drop-ins are welcomed. A referral by a Family Physician is not required; patients/families/ teachers, etc may all refer. We work with the family and the community, as well as the schools, to make ourselves and the other health-care professionals whom we may refer our patients to, more accessible, recognizing the many obstacles that people who live in poverty, face.
A huge part of our work is dedicated to advocacy; for the patients and for their families. money saving at payday advance
exercise in treatement of hyperlipidemia
Lifestyle interventions, in the form of dietary modification and exercise, are effective means of managing and treating high serum levels of cholesterol and triglycerides in individuals diagnosed with dyslipidemia. Such interventions should always be attempted as the initial step in the management and treatment of lipid abnormalities, especially when total cholesterol levels, low-density lipoprotein (LDL) levels, or triglyceride serum levels are just above the reference range.
EFFECT OF EXERCISE ON DYSLIPIDEMIA
The acute effects of exercise on serum lipid levels are greatest with respect to elevating the levels of high-density lipoprotein (HDL). Various studies have shown HDL levels to increase by 4-43% with exercise. A reduction in triglyceride (TG) levels also occurs 18-24 hours after an acute bout of exercise and can persist for up to 72 hours. This effect is greatest in those with the highest pre-exercise TG values and does not appear to require a threshold of exertion to be demonstrated. The chronic effects of exercise were studied among endurance athletes. It was noted that they frequently had serum HDL cholesterol concentrations 10-20 mg/dL or 40-50% higher than their sedentary counterparts. Their triglyceride levels were also lower by 20%, and their LDL cholesterol concentrations were lower by approximately 5-10%.
The Health, Risk Factors, Exercise, Training, and Genetics (HERITAGE) Family Study showed that regular endurance exercise training was particularly helpful in men who have low HDL cholesterol levels, elevated TG levels, and central or abdominal obesity. The increase in HDL levels was usually noticed at 12 weeks or more and not seen at 10 weeks or less. Increased training volume predictably yielded greater results. The increase in HDL levels was more profound when exercise was combined with caloric restriction.
EFFECT OF DIET ON DYSLIPIDEMIA
Although the diet commonly recommended for patients with dyslipidemia is low in saturated fat (<10% of caloric intake), low in cholesterol (<300 mg/d), and high in soluble fibers, several other diets have also been tried with reasonable success. Among them, the Mediterranean diet was a particularly effective alternative. This diet is low in red meat; high in fruits, vegetables, whole grains, beans, nuts, and seeds; and low to moderate in fish, poultry, and dairy products. Another suggested diet alternative contains diverse cholesterol-lowering components. This diet is low in saturated fat and high in plant sterols, soy protein, viscous fibers, and almonds. The level of LDL reduction with this second alternative diet was not statistically significant from a diet very low in saturated fat plus 20 mg/d of lovastatin. Meanwhile, increasing the percentage of monounsaturated fat intake and reducing caloric intake from carbohydrates to around 40% was also shown to reduce both fasting and postprandial triglyceride levels and increase HDL levels.
DIETARY SUPPLEMENTS AND DYSLIPIDEMIA
Several over-the-counter dietary supplements are frequently selected by dyslipidemic patients or are taken upon the recommendation of health care professionals.
- Fish oil
Most of the data used to support the intake of fish oil concentrate were derived from studies that used high daily doses (>6 g/d). These studies conclusively showed significant reduction in serum triglyceride levels through inhibition of very low-density lipoprotein (VLDL) triglycerides and apolipoprotein B synthesis. In hypertriglyceridemic subjects, a dose of 15 g/d of fish oils lowered serum triglyceride levels by approximately 50%. Although many trials support the cardioprotective effects of fish oil, recent epidemiologic evidence, unfortunately, does not. The precise reasons for these controversial findings have yet to be determined. Variations in the apolipoprotein E (apoE) genotype may play a role in an individual’s specific response to fish oil therapy. In particular, an increase of LDL-C levels and a trend in the direction of reduced HDL-C levels after fish oil supplementation were observed in subjects possessing the apoE4 allele, compared to individuals possessing the homozygous apoE3 allele profile. Additionally, individuals possessing the apoE2 allele have shown improved responses to reduction of expected serum triglyceride elevations after meals.
- Oat bran supplement
Beta-glucan (the main soluble fiber component of oat bran) may decrease the absorption of ingested nutrients and bile acids by increasing the viscosity of intestinal contents. Several studies have demonstrated evidence that oat bran supplements have a substantial hypocholesterolemic effect. A daily dose of 3 grams or more is required to produce clinically relevant reductions in both total cholesterol (TC) and LDL concentrations. Combining oat bran supplementation with exercise showed consistent and substantial reduction of serum lipid levels.
- Plant sterols
Compounds that are structurally similar to cholesterol were shown to lower serum lipid levels by inhibiting intestinal cholesterol absorption. Plant sterols include vegetable oils, seeds, and nuts. A meta-analysis of 21 trials that used plant sterol supplements showed that a dose of 2 g/d reduced serum LDL levels by approximately 10%. Although plant sterols consistently lower TC and LDL concentrations, evidence suggests that these nutritional supplements have no effect on HDL or TG levels. Combining plant sterols of 1.8 g/d with 25-40 minutes of endurance physical exercise 3 times per week resulted in universal reduction of TC, LDL, and TG levels and an increase in HDL levels. Money saving for future health fast cash