Intensive Multidisciplinary Treatment Research Articles

Service responses for youth onset mental disorders

Many psychiatric disorders have their highest first-onset rates in adolescence and young adulthood. We summarize recent work indicating where interventions are most needed and effective. We also review the literature that examines the scope for reorienting mental health services to meet the needs of adolescents and young adults. The continuities between youth onset and later life disorders, as well as later social adjustment, have become clearer. Emotional disorders that persist or recur during the teens have the greatest effect on future mental health. To date, service systems, even in the developed world, cater poorly for youth with mental disorders. Intervention studies demonstrate the short-term benefits of intensive multidisciplinary intervention for early psychosis. There are few data concerning the benefit of early intervention for other disorders. Long-term benefits for early intervention for any condition are unknown. Youth streams of psychiatric care have developed for early-onset psychotic disorders. An increasing understanding of the high prevalence and longer-term effects of youth onset mental disorders has not yet been adequately matched by intervention research or the evaluation of different models of mental health service delivery.

Changes after multidisciplinary pain treatment in patient pain beliefs and coping are associated with concurrent changes in patient functioning

Little is known about how patient functioning changes after completion of multidisciplinary pain programs, and what factors are associated with such changes when they occur; for example, whether improvement or deterioration in functioning corresponds to changes in patient beliefs and coping during this period. The objective of this study was to examine the extent to which changes in patient pain and functioning were associated with changes in beliefs and coping after multidisciplinary pain treatment. Patients with chronic pain ( N = 141) completed outcome (pain, functioning) and process (beliefs, catastrophizing, coping) measures at the end of multidisciplinary pain treatment and 12 months posttreatment. On average, patients reported similar levels of pain at both times, but showed a small worsening in disability and depression outcomes between posttreatment and follow-up, which were associated significantly with concurrent changes in the process measures. In particular, increased belief in oneself as disabled by pain, catastrophizing, and increased use of resting, guarding and asking for assistance in response to pain were linked with increased disability and depression. Decreased perceived control over pain was also consistently associated with worsening of these outcomes. The results highlight the potential importance of specific pain-related beliefs and coping responses in long-term patient pain and adjustment. Research is needed to determine whether booster interventions after the end of intensive multidisciplinary treatment that target these beliefs and coping responses improve long-term outcomes.

420 SIGNIFICANCE OF GENETIC AND NEUROPHYSIOLOGICAL ASPECTS IN FIBROMYALGIA

Background and Aims: The published experience about the multidisciplinary treatment of fibromyalgia is controversial. Our aim is to describe the results of our multidisciplinary treatment in a group of selected fibromyalgia patients with disability, and willing to return to work. Methods: After multidisciplinary meeting, 264 patients with fibromyalgia (94% female; mean age 43 (8.6) years) were included in the study, and allocated by consensus to an intensive medical, psychological, physical and occupational treatment (twelve sessions, three-day weekly basis). Patients were affected by significant disability, were free of major psychopathology (suicide risk, schizophrenia or other psychotic disorders, and severe personality disorder), considered return-to-work as a therapeutic aim, and were not applying for disability pension or in the course of labor litigation. All patients were followed at discharge, and at 6 and 12 months. Results: Significant differences were observed in pain (VAS) at discharge (Mean difference: 3.1; p< 0.01), at 6 and at 12-month follow-up (Mean difference: 2.1 and 3.2; p< 0.01), in depressive symptoms at discharge and at 12 month follow-up (Mean difference (BDI): 5.7 and 8.4; p< 0.01), and in functional ability (HAQ) at discharge, at 6 and at 12 month follow-up (Mean difference: 0.8, 0.8 and 0.9 respectively p< 0.01). At discharge, 63% of patients returned to work. Conclusions: The intensive multidisciplinary treatment for fibromyalgia is effective in patients with possibilities of functional restoration, and willing to return to work.

Functionally Oriented Rehabilitation Program for Patients with Fibromyalgia

To evaluate function and disability in patients with fibromyalgia before and after participation in a functionally oriented, multidisciplinary, 8-wk treatment program. A total of 23 patients who met American College of Rheumatology criteria for the diagnosis of fibromyalgia were enrolled in the study. Outcome measures included: range of motion, 6-min walk test, a modified Fibromyalgia Impact Questionnaire, a modified SF-36 Physical Functioning Scale, and the Fibromyalgia Health Assessment Questionnaire. Pretreatment and posttreatment scores were analyzed using paired t tests. All subjects completed the program, and there were no reported injuries. Three subjects failed to complete the survey instruments at the conclusion of the study. Intention to treat analysis including these subjects was carried out but did not significantly change results. For the remaining subjects (n = 20), a significant improvement was found on the Physical Functioning Scale (P = 0.01). Trends toward improvement on the Fibromyalgia Impact Questionnaire (P = 0.40) and Fibromyalgia Health Assessment Questionnaire (P = 0.14) were seen but did not achieve statistical significance. Range of motion testing revealed significant improvements in lumbar spine extension (P < 0.001), straight-leg raise (P < 0.001), cervical spine flexion (P < 0.01), cervical spine rotation (P < 0.05), and cervical spine side bending (P < 0.05). Distance traveled during the 6-min walk test increased significantly (P < 0.01), whereas perceived exertion as measured by the Borg scale did not change. There were no injuries or other adverse consequences of the program. This study utilized multiple functional outcome measures to demonstrate improved function and decreased disability in patients with fibromyalgia. Our patients reported significantly improved physical function after participation in the 8-wk intensive multidisciplinary treatment program. This progressive, functionally based exercise training program was well tolerated by all participants and outlines an effective exercise prescription for patients with fibromyalgia. Fibromyalgia patients in this study responded favorably to a treatment program that focused on function instead of pain.

Check-ups in obese and diabetic patients: Preventive Medicine

Obesity is a chronic disease associated with important additional diseases, such as DM 2, that both reduce life quality and increase morbimortality from any cause. In the Western world, obesity is directly responsible for most deaths due to associated chronic disease. Therefore, substantial effort should be directed towards adequate primary prevention campaigns and policies, as well as towards an intensive and long-term multidisciplinary treatment of obesity, in an attempt to combat this threat to the health of a large part of our population.

Multidisciplinary Group Rehabilitation Versus Individual Physiotherapy for Chronic Nonspecific Low Back Pain

A randomized trial. To evaluate the effectiveness of a semi-intensive multidisciplinary rehabilitation for patients with chronic low back pain in an outpatient setting. Systematic reviews have shown that there is strong evidence that intensive multidisciplinary treatment (>100 hours), which includes functional restoration, improves function among chronic patients with low back pain, and moderate evidence that it reduces pain but contradictory evidence regarding improvement of working ability. However, there is paucity of data whether semi-intensive outpatient multidisciplinary rehabilitation in groups is more effective than individual physiotherapy. A total of 120 women employed as healthcare and social care professionals with nonspecific chronic low back pain were recruited from two occupational healthcare centers. The patients were randomized into two intervention programs. Multidisciplinary rehabilitation (n = 59) was conducted in groups and comprised of physical training, workplace interventions, back school, relaxation training, and cognitive-behavioral stress management methods for 70 hours. The individual physiotherapy (n = 61) included physical exercise and passive treatment methods administered for 10 hours. Main outcome measures were: back pain and sciatic pain intensity, disability, sick leaves, healthcare consumption, symptoms of depression, and beliefs of working ability after 2 years. There were no statistically significant differences between the two treatment groups in main outcome measures just after rehabilitation, at 6-, at 12-, or 24-month follow-up. In both intervention arms, however, the before-and-after comparison showed favorable effects, and the effects were still maintained at 2 years follow-up. The results of this study indicate that semilight outpatient multidisciplinary rehabilitation program for female chronic low back pain patients does not offer incremental benefits when compared with rehabilitation carried out by a physiotherapist having a cognitive-behavioral way of administering the treatment.

Outcome of non-invasive treatment modalities on back pain: an evidence-based review.

At present, there is an increasing international trend towards evidence-based health care. The field of low back pain (LBP) research in primary care is an excellent example of evidence-based health care because there is a huge body of evidence from randomized trials. These trials have been summarized in a large number of systematic reviews. This paper summarizes the best available evidence from systematic reviews conducted within the framework of the Cochrane Back Review Group on non-invasive treatments for non-specific LBP. Data were gathered from the latest Cochrane Database of Systematic Reviews 2005, Issue 2. The Cochrane reviews were updated with additional trials, if available. Traditional NSAIDs, muscle relaxants, and advice to stay active are effective for short-term pain relief in acute LBP. Advice to stay active is also effective for long-term improvement of function in acute LBP. In chronic LBP, various interventions are effective for short-term pain relief, i.e. antidepressants, COX2 inhibitors, back schools, progressive relaxation, cognitive-respondent treatment, exercise therapy, and intensive multidisciplinary treatment. Several treatments are also effective for short-term improvement of function in chronic LBP, namely COX2 inhibitors, back schools, progressive relaxation, exercise therapy, and multidisciplinary treatment. There is no evidence that any of these interventions provides long-term effects on pain and function. Also, many trials showed methodological weaknesses, effects are compared to placebo, no treatment or waiting list controls, and effect sizes are small. Future trials should meet current quality standards and have adequate sample size.

Eficacia del tratamiento multidisciplinario del dolor crónico incapacitante del aparato locomotor

Disabling chronic pain is especially devastating among working population and, in many cases, it does not respond to conventional therapies. In chronic pain, the importance of psychosocial and occupational factors, in addition to biological ones, has prompted the development of successful multidisciplinary treatment programmes in various countries. We assessed the outcome of a multidisciplinary therapeutic program for work-disabled selected patients with chronic pain refractory to conventional treatment. The study included 70 patients (58 women, mean age [SD]: 42 [9]years) with chronic pain and sick leave (mean [SD]: 7 [4] months of work disability) diagnosed with fibromyalgia (51%), chronic low back pain (16%), regional myofascial pain (15%), cervicocraneal syndrome (3%), anquilosing spondylitis (3%), and other conditions(12%). All patients had received previous pharmacological treatment,physical therapy and/or other measures (surgery in 12% cases)without improvement. All patients underwent an intensive multidisciplinary treatment of 4 weeks' duration including medical techniques for pain control, cognitive-behavioural therapy, physical therapy,and occupational therapy. Average follow-up was 10 (4) months(1-24 months) post-discharge. Significant improvements were observed with regard to all relevant variables, as reflected in pre and post-discharge measures: pain(Visual-Analogue Scale 1-10 cm): 7.4 (1.5) versus 3.2 (2) (p <0.01); anxiety (HARS), 19 (7) versus 14 (8) (p < 0.01); depression(BDI), 16 (8) versus 10 (8) (p < 0.01); functional ability(HAQ), 1.6 (0.4) versus 0.6 (0.5) (p < 0.001). At discharge,73% of patients returned to work. In addition, 69% of treated patients maintained the acquired improvement and their employment status at the end of follow-up. Multidisciplinary treatment of chronic pain with special attention to work return is useful for selected patients with a disabling chronic pain syndrome refractory to conventional treatment.

Prevention of hospitalizations for heart failure with an interactive home monitoring program

Congestive heart failure is the most common cause of hospitalization for the older population. A previous study demonstrated that rehospitalizations, undertaken by 30% to 50% of elderly patients, can be prevented with intensive multidisciplinary intervention. A pilot study was designed to determine whether a less intensive program with patient education materials, automated reminders for medication compliance, self-monitoring of daily weights and vital signs, and facilitated telephone communication with a nurse-monitor could reduce hospitalizations and whether this benefit could be extended to younger outpatients. Twenty-seven male patients (mean age 62 years) with New York Heart Association class II to IV congestive heart failure caused by dilated cardiomyopathy underwent follow-up with an independent service, which provided the primary cardiologist with information concerning changes in vital signs or symptoms. The number of hospitalizations and hospital days during the mean value of 8.5 months in the program was compared patient by patient with the number during the equivalent period before entrance in the program. The number of hospitalizations for cardiovascular diagnoses and hospital days was reduced from 0.6 to 0.2 ( p = 0.09) per patient year of follow-up and 7.8 to 0.7 days per patient per year ( p < 0.05). Hospitalizations for all causes fell from 0.8 to 0.4 per patient per year ( p = not significant) and 9.5 to 0.8 days per patient per year ( p < 0.05). The greatest absolute and relative benefit was observed among patients with more severe congestive heart failure. The most frequent indication for intervention was an increase in weight, which was managed with adjustment of diuretic dosages. This preliminary experience suggests that close telephone monitoring by personnel from an independent service can prevent hospitalizations for heart failure among both recently discharged patients and ambulatory outpatients and among both elderly and middle-aged persons. (Am Heart J 1998;135:373-8.)

Managed Care: It May Be an Opportunity

It is well documented and clinically understood that the course of recovery from posttraumatic brain injury may extend over a long period of time. However, all too often a client's benefits are exhausted during the early phase of rehabilitation. As a consequence the client's emotional, psychosocial, vocational, and avocational rehabilitative needs are either addressed minimally or not at all. When these needs are not met it is not uncommon to find that clients regress from the level of independence they gained in the early phase of rehabilitation in which the majority ifnot all of their funds have been expended. To a considerable extent the lack of funds to finance the entire continuum of rehabilitation is related to reimbursement criteria established by the payors. These criteria focus primarily on frequency and intensity of rehabilitative intervention. Providers must demonstrate that a client requires intensive multidisciplinary intervention in order tojustif)' admission to and continued stay in an inpatient hospital or residential rehabilitation program. However, not all clients need the interventions of all disciplines nor do all clients benefit from the simultaneous intervention of all disciplines. The managed care approach holds the potential to allow providers the opportunity to more closely align their service delivery format with the prevailing needs of a client across the entire continuum of rehabilitation. Managed care will not base reimbursement on frequency and intensity of services provided by specified disciplines. Instead reimbursement will be based upon a predetermined and negotiated outcome, length

Disability Exaggeration as a Predictor of Functional Restoration Outcomes for Patients with Chronic Low-Back Pain

Many of the individual biological, psychological, and social factors attributed to low-back disability have been tested previously for their ability to predict treatment outcomes. To test the assumption that disability exaggeration affects treatment outcomes, models were developed to quantify this complex characteristic and to test its predictive value. Two hundred fifty-eight patients with chronic back disability entering a program of functional restoration were initially evaluated with a battery of tests, including measurements of trunk flexibility, lifting capacity, cycling endurance, self-assessments of pain and disability, and psychological attributes. On the basis of these measurements, patients were characterized as disability exaggerators if by peer comparison their self-assessments of pain and disability were in the most severe range despite high levels of physical capacity. Program completion and work status 1 and 2 years after treatment were compared between disability exaggerators and their peers. Individual initial attributes associated with program completion included pain intensity and Million Visual Analogue scores, lifting capacity, trunk flexibility, some Minnesota Multiphasic Personality Inventory and Million Behavioral Health Inventory scales, and cigarette smoking. One-year re-employment was associated with Minnesota Multiphasic Personality Inventory Scale 8, Wechsler Adult Intelligence Score-Revised, and cycling endurance. There were no significant associations between any individual factor and 2-year work status. Only two of the 12 disability exaggeration models distinguished between program graduates and dropouts, and none of the models accurately predicted return to work following treatment. Prescription of intensive multidisciplinary treatment should not be denied on the basis of any individual patient attribute or of disability exaggeration, as measured in this study.(ABSTRACT TRUNCATED AT 250 WORDS)

Testicular Cancer in Children.

Management of testis cancer in children differs from that in adults due to the histological types and varying tolerances to chemotherapy agents. Embryonal adrenocarcinoma (endodermal sinus tumor, Teilum's tumor) is a tumor of infancy and young children and less aggressive than other testis cancers. Most cases require only orchiectomy for cure. Embryonal carcinoma is seen in older children and is managed by orchiectomy, regional node dissection, and chemotherapy according to stage. Teratocarcinoma is seen in older age groups. In the young children, as rhabdomyosarcoma and neuroblastoma are often present. Intensive multidisciplinary treatment is required in management. Paratesticular rhabdomyosarcoma arising in the distalcord requires pelvic and retroperitoneal node dissection in addition to orchiectomy. Chemotherapy and radiation therapy help to produce high cure rates in these tumors. Details of the treatment of these histological types and results of treatment will be presented.