Connections between musculoskeletal complaints and personality

Modern research has demonstrated a weak association between level of muscle tension and experience of muscle pain. Anxiety and dysphoric over-responsiveness are the traditional psychogenic risk factors in muscle tension. Results from recent Norwegian research lend support to a more multidimensional causal understanding of muscle tension and of pain. Generally, personality factors were found to be a contributory cause of muscle pain of the neck and shoulders, whereas ergonomic load was found to be of greater significance for low back pain. Personality factors may induce patterns of skeletal muscle activation discrepant with characteristics of the skeletal muscle physiology: Preference for aerobic activities may develop through social learning, whereas the muscles may be genetically biased toward anaerobic activities. Furthermore, personality factors may be challenged by the work setting, and may result in mismatch that provokes muscle pain. Impatient expenditure of effort has appeared as a mediating personality risk factor among workers exposed to high ergonomic load, whereas dysphoric over-responsiveness mediated back pain primarily among staff exposed to high emotional load.     

The occurrence of musculoskeletal alterations in worker populations not exposed to repetitive tasks of the upper limbs

A total of 749 workers (males: 139 aged between 15 and 35 years, and 171 aged > 35 years; females: 176 aged between 15 and 35 years, and 263 aged > 35 years) performing tasks not at risk for work-related musculoskeletal disorders of the upper limbs (WMSDs) underwent a clinical examination using a standardized method. The 'anamnestic cases' were defined on the basis of pain or paraesthesia present for at least 1 week during the previous 12 months, or appearing at least once a month, and not subsequent to acute trauma. The anamnestic cases among the males amounted to 4.4% (age 15-35 years) and 12.3% (age > 35 years); among the females, 4.6% (age 15-35 years) and 14.2% (age > 35 years). Of the 1498 limbs examined, the prevalent diseases reported were: suspect narrow chest syndrome: 0.3% among the males > 35 years, 0.6% among the females aged 15-35 years, 1% among the females > 35 years; scapulo-humeral periarthritis: 0.3% among the males aged > 35 years, 0.3% among the females aged 15-35 years, 1.3% among the females aged > 35 years; lateral epicondylitis: 0.3% among the males aged > 35 years, 0.2% among the females aged > 35 years; trapeziometacarpal arthrosis: 0.8% among the females aged > 35 years; wrist-hand tendinitis: 0.9% among the males aged > 35 years, 0.9% among the females aged 15-35 years; carpal tunnel syndrome: 2.5% among the females aged > 35 years. No disorders were detected outside the age ranges indicated. Several workers reported more than one disorder. The number of workers with at least one WMSD was: males 0% in the 15-35 years age range, 3.5% in the > 35 years age range; females 2.3% in the 15-35 years age range, 7.2% in the > 35 year age range; 3.9% of the total sample population. The prevalences were on average quite low, particularly among the older workers, hence the authors recommend that even minimal prevalences detected in particular work environments should not be underestimated.     

Giant cell arteritis involving the lower limbs

Giant cell arteritis is an inflammatory disease that can affect the arteries anywhere in the body. Two cases are reported in which the arteries of the lower limbs were involved. Intermittent claudication with a walking distance of only 30 m was the inaugural manifestation in both cases. A biopsy of the superficial femoral artery provided the diagnosis in the first case. Ergotamine toxicity was considered initially in the second case. Acute ischemia and gangrene requiring amputation can complicate giant cell arteritis of the lower limbs and consequently corticosteroid therapy in an effective dose should be given as soon as the diagnosis is made. The inflammatory arterial lesions improve under therapy, but irreversible fibrosis with stenosis can develop if treatment is initiated late.     

Work capacity of the upper limbs after mastectomy

A 59-year-old man presented with neck pain and limb numbness. He also had bilateral symmetrical joint deformities of his hands and wrists. Cervical spine radiographs showed C 1/2 instability and features of rheumatoid arthritis. Magnetic resonance imaging demonstrated erosion ofthe odontoid peg by pannus. C 1/2 surgical fusion was performed. The role of imaging in cervical spine involvement by rheumatoid arthritis is reviewed.     

Clinical trials among worker populations: the value and significance of anamnestic findings and clinical and instrumental tests for diagnosing work-related musculoskeletal disorders of the upper limbs (WMSDs)

The authors discuss the value and significance of symptoms in WMSDs, in view of the fact that the anamnestic threshold proposed in epidemiological investigations cannot be used as clinical and diagnosing criteria. Some useful clinical procedures are suggested for cases where there is a suspicion of musculoskeletal disorders of the cervical spine and upper limbs, bearing in mind that they are to be applied within the framework of health surveillance programmes undertaken by health care practitioners who are not specialists in orthopaedics, physiatrics or neurology. The recommendations for instrumental tests and specialist referrals are also discussed for the various disorders. The authors also provide flow charts for the diagnostic procedures pertaining to WMSDs. The appendix shows a sample patient chart illustrating the proposed procedures; it also permits the findings to be encoded so that they can be stored in a dedicated database. The codes for diagnosing WMSDs are also reported for the same epidemiological purposes.     

Formal complaints and disciplinary proceedings involving medical practitioners: recent developments in New South Wales, Australia

Complaints against medical practitioners are of interest to all the stakeholders in health care who are concerned with quality assurance and its definition, implementation and monitoring. New South Wales,Australia, has recently made statutory provision for independent structures of complaint investigation and resolution, including revised disciplinary proceedings to protect the public interest and regulate the conduct of the state's medical profession. This article discusses the new mechanisms and recent experience of them. They are intended to offer independence and an integrated and comprehensive system of grievance procedures but there remains a need for disciplinary procedures that afford lay control over the regulation of medical conduct.     

Reconstruction of defects involving the upper one-third of the auricle

STUDY OBJECTIVES: The peak inspiratory flow rates (PIFRs) generated by cystic fibrosis (CF) and COPD patients through a range of clinically relevant resistances have not yet been reported (to our knowledge). The objectives of this study were to (1) explore a relevant range of resistive loads and address whether patients with stable CF and COPD can generate the PIFR sufficient to disperse dry-powder inhalants (DPI) and (2) determine whether the optimal inspiratory flow rate effective for delivery of aerosolized pharmacologic therapeutic agents can be attained with a comfort rating acceptable to subjects. DESIGN: Prospective, controlled, subject-blinded study. SETTING: Pulmonary function laboratory at the VA Palo Alto Health Care System. PATIENTS OR PARTICIPANTS: Thirty-six subjects, including 12 healthy volunteers, 12 subjects with CF, and 12 subjects with COPD were studied. MEASUREMENTS: Studies of dynamic lung function and PIFR without and with varying resistances were obtained at a single laboratory visit. RESULTS: Dynamic lung function and PIFR varied inversely with the resistive load for all patient groups and did not correlate with the disease severity, as indicated by FEV1 of percent predicted. The average subjective comfort rating for any given resistive load was similar for subjects with CF and COPD. CONCLUSIONS: These results support the conclusion that subjects with stable CF and COPD of varying severity can comfortably generate the necessary flow rates to operate new and currently available DPIs over a wide range of inspiratory resistances.     

Positioning for clinical dental hygiene care. Preventing back, neck and shoulder pain

Spasmodic dysphonia is a focal dystonia that effects the proximal muscles (adduction dystonia) or dilatory (abduction dystonia) of the larynx. Botulinum toxin (BTX), generally delivered by percutaneous injection, is the treatment of choice. Recently, use has been made of a transoral route of delivery, with BTX injected through a curved device with visual control. It remains to be determined which route is better. Percutaneous injection is simple and well-tolerated, but the transoral route is theoretically more effective. We assessed the efficacy of both techniques in 19 patients with adduction dystonia, conducting 55 treatment sessions by percutaneous injection and 20 by transoral injection. All the transoral treatments were effective (20/20, 100%), but only 81% (45-155) of the percutaneous treatments were (p < 0.05). Two patients who had doubtful responses after percutaneous delivery improved considerably when the transoral approach was used. In spite of its greater complexity, the transoral approach is probably more effective than the percutaneous route. We describe a curved device for transoral injection that is composed of simple elements available at any health center.     

Application of the concise exposure index (OCRA) to tasks involving repetitive movements of the upper limbs in a variety of manufacturing industries: preliminary validations

A summary of eight investigations is presented, which were carried out using standardized methods, for the purpose of quantifying exposure to tasks involving repetitive movements of the upper limbs, as well as quantifying the prevalence of work-related musculoskeletal disorders (WMSDs) of the upper limbs in groups of exposed workers. A total of 462 exposed workers were examined, and the study also took into account the data pertaining to a matched reference group comprising 749 workers not exposed to any specific occupational risk. Regarding the quantification of exposure to increased risk, use was made of a concise index (OCRA index), proposed by Occhipinti, in this issue. The data resulting from the eight investigations were used for the study of measurements and models of association among the exposure variables (mainly represented by the OCRA index), as well as the effect variables represented by the prevalence of the various WMSDs of the upper limbs taken both individually and jointly. Significant associations were reported between the OCRA index and an effect indicator represented by the prevalence of all the WSMDs of the upper limbs, calculated on the number of upper limbs at risk. When a logarithmic conversion of the relative exposure (OCRA) and injury indices was carried out, a simple linear regression model resulted that seems to provide a satisfactory predictive performance of the risk of WMSDs of the upper limbs, based on the exposure index. The study confirmed the efficacy of various other models designed to predict effects based on multiple linear regression functions, in which the independent variables are represented by both the OCRA exposure index and by parameters relative to the breakdown by gender and age of the groups of exposed workers.     

Coping with neck and low back pain in the general population.

This study had 2 objectives: (a) to assess the psychometric properties of the Pain Management Inventory (PMI; G. K. Brown & P. M. Nicassio, 1987) with individuals in the general population with neck or low back pain, and (b) to assess the relationship between pain severity and coping. Data were taken from a mailed survey of a random sample of adults residing in Saskatchewan, Canada. Results validated the 2-factor structure of the PMI and provided evidence for the internal consistency of the coping subscales. Regression analyses revealed that passive coping was associated with being married, greater pain severity, depression, and poor health. Active coping was associated with female gender, higher education, less depression, good health, and frequent exercise. This study provides psychometric data to support the use of the PMI and information about factors associated with use of active and passive coping strategies in pain sufferers. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

An observational method for classifying exposure to repetitive movements of the upper limbs

This article presents and discusses a model for describing and evaluating the principal risk factors characterizing occupational exposure: frequency and repetitiveness of movements; use of force; type of posture and movements; distribution of recovery periods; and presence of other influential (additional) factors. For each risk factor, the author proposes a method of practical detection in the field, as well as criteria for classifying and interpreting the results based on a critical review of the available literature on the subject. Numerous examples are supplied to better illustrate the concepts presented. The various factors considered are classified using numbers or indexes, so that they can be integrated into a concise exposure index.     

Differential diagnosis of a mass in the upper lateral neck

The differential diagnosis and the duration of symptoms are presented for a group of 288 patients encountered over a ten-year period with a mass in the region of the neck behind and below the angle of the mandible. While infections constituted the largest aetiological group (48.3 per cent), 109 cases (37.9 per cent) had some form of neoplasia, with malignancy being found in 48 (16.6 per cent). The duration of symptoms varied widely, only the acute infections having an acceptably short delay prior to hospital admission. The mean symptom duration for all the neoplastic cases was in excess of five months.     

A family with neurogenic atrophy of the distal muscles of the upper limbs: clinical and electrophysiological studies

A Chinese family manifested mild neurogenic atrophy of the distal muscles of the upper limbs. None of the affected members had sensory abnormalities, or pyramidal tract or bulbar involvement. The onset of the illness was in the middle of the second decade of life. The muscle atrophy was more severe in the female members. Electromyographic examination of the atrophic muscles showed evidence denervation. One female patient demonstrated slow motor conduction velocity in the right median nerve.     

Prevalence of upper abdominal complaints and their effect on the quality of life and utilization of medical resources. Swiss Primary Care Group

The authors present the results obtained in Switzerland, as part of an international survey (DIGEST), on 3 months' prevalence of upper digestive symptoms (UDS) and their influence on quality of life and consumption of medical services. 514 randomized adults from the general population in 8 different cities were interviewed. In these interviews data were recorded concerning demographic and socio economic aspects, quality of life, severity and frequency of UDS, consultations and medication. The sub-population with relevant UDS (i.e. UDS at least once a week and/or of moderate to severe degree) was compared with the rest of the population interviewed. 19% of the interviewees reported relevant UDS; of these, two thirds were women. No differences were found between people with and without UDS as far as education, professional activities, consumption of alcohol or smoking are concerned. The most frequent symptoms reported were fullness, bloating and nausea. However, daily activities were most impaired by nausea, epigastric pain and heartburn. Interviewees with UDS more frequently reported "life events" in the preceding year (48% vs 33%). Interviewees with UDS also more frequently reported back pain (7% vs 2%) and migraine (10% vs 6%). Furthermore, more interviewees with UDS reported sick leave (11% vs 3%); they also had a poorer life quality score (74 vs 89, PGWBI), reported more medical visits (50% vs 19%) and consumed more medication, both prescribed (65% vs 25%) and non-prescribed (OTC: 70% vs 31%).     

Osteochondroma of the femoral neck secondary to a slipped upper femoral epiphysis

Traumatic osteochondromas may develop following damage to the growth plate, but these lesions are rare. Osteochondromas developing secondary to a slipped upper femoral epiphysis (SUFE) have not been previously described. We report such a case and discuss its pathogenesis in relation to the possible aetiologies of primary osteochondromas and SUFE.     

OCRA: a concise index for the assessment of exposure to repetitive movements of the upper limbs

In the light of data and speculation contained in the literature, and based on procedures illustrated in a previous research project in which the author described and evaluated occupational risk factors associated with work-related musculoskeletal disorders of the upper limbs (WMSDs), this paper proposes a method for calculating a concise index of exposure to repetitive movements of the upper limbs. The proposal, which still has to be substantiated and validated by further studies and applications, is conceptually based on the procedure recommended by the NIOSH for calculating the Lifting Index in manual load handling activities. The concise exposure index (OCRA index) in this case is based on the relationship between the daily number of actions actually performed by the upper limbs in repetitive tasks, and the corresponding number of recommended actions. The latter are calculated on the basis of a constant (30 actions per minute), which represents the action frequency factor; it is valid--hypothetically--under so-called optimal conditions; the constant is diminished case by case (using appropriate factors) as a function of the presence and characteristics of the other risk factors (force, posture, additional elements, recovery periods). Although still experimental, the exposure index can be used to obtain an integrated and concise assessment of the various risk factors analysed and to classify occupational scenarios featuring significant and diversified exposure to such risk factors.     

Public complaints and the emergency department

The effect of various cytokines including rIL-1, rIL-2, rIL-3, rIL-4, rIL-6, and growth factors including rNGF, rILGF and rEPGF on the post transplant immunodeficiency after allogeneic bone marrow transplantation was explored in 8 patients. The results show that neither cytokine alone was able to increase the proliferative capability in post transplant lymphocytes, however, when added in conjunction a significant increase in PHA driven proliferation was noted. Any significant lack of growth factors is probably not the only cause of immunodeficiency post transplant, since addition of any of these compounds did not have any influence on the lymphocyte proliferation, and so the data presented here suggest that therapeutic application of any of the investigated cytokines or growth factors to such patients is unlikely to be successful in overcoming the defects of T cell function post grafting.