Non-pharmacological Treatment Methods Research Articles

Cases of chronic insomnia patients treated by group cognitive behavioral therapy for insomnia

Pharmacotherapy is currently widely used in the treatment of insomnia can be helpful in transient insomnia, but research regarding its effectiveness and safety of long-term use is not enough. Therefore, to complement the limitations of pharmacotherapy in the treatment of patients with insomnia, non-pharmacologic treatment methods (cognitive behavioral therapy; CBT) are used. But CBT for insomnia appear to be costly and time-consuming compared to pharmacotherapy, clinical practice in the field can be difficult to apply. The authors took the format of group therapy rather than individual therapy to complement the disadvantages of CBT and now we would like to have a thought into its meaning by reporting several cases of patients who reduced taking sleeping pills through group CBT. Patients were recruited at Sleep Center of St. Vincent’s hospital, 2 men and 3 women led to a group of five patients. CBT is a treatment for correction factors that cause and maintain insomnia, it includes a variety of techniques such as sleep hygiene education, stimulus control, sleep restriction, relaxation and cognitive therapy. A series of treatment were performed five sessions once a week with a frequency from February to March 2012 and were proceeded for about 1hour and 30 min per session. Results indicated that the subjective quality of sleep and sleep efficiency of all patients improved and PSQI (Pittsburgh Sleep Quality Index) and BDI (Beck Depression Inventory) were decreased in spite of reducing dose of medication. Like these cases, we can contribute to reduce the time and economic burden by performing group therapy for insomnia CBT rather than individual therapy. Keywords: Insomnia, Cognitive Behavioral Therapy, Group therapy. Pharmacotherapy There are no conflicts of interests.

Chronic Pain and Health Services Utilization

Few studies have described patterns and determinants of health services utilization (HSU) in chronic pain (CP) subjects. We aimed to describe these, in particular, regarding medical consultations (MCs), diagnostic tests (DTs), pain medicines (PMs) and nonpharmacologic treatment methods (NTM) utilization. A cross-sectional nationwide study was conducted in a representative sample of the Portuguese population. The 5094 participants were selected using random digit dialling and were contacted by computer-assisted telephone interviews. Questionnaires included the brief pain inventory and pain disability index. Estimates were adequately weighted for the population. Prevalence of CP and CP with moderate to severe disability was 36.7% and 10.8%, respectively. Most CP subjects were being managed/treated by health professionals (81%) and had high levels of HSU. More than half of them had used imaging DT in the previous 6 months. Main factors associated with HSU were as follows: pain-related disability, intensity, duration, and depressive symptoms for MC utilization; sex, pain-related disability, and duration for PM utilization; and education level and depression diagnosis for NTM utilization. The main drivers behind HSU are pain severity, psychological distress, and socio-economic determinants. An important set of benchmarks are presented regarding HSU in CP subjects, comprising useful tools for public health policy and decision-making. Results presented may suggest possible inequalities in the access to NTM, and interventions to improve access are encouraged. Moreover, possible indirect evidence of imaging DT overuse is presented, and it is recommended that their use in CP subjects should more closely follow existing guidelines.

The Pharmacological Management of Post-Stroke Muscle Spasticity

Muscle hypertonia following upper motor neurone lesions (referred to here as 'spasticity') is a common problem in patients with neurological disease, and its management is one of the major challenges in clinical practice. Understanding the pathogenesis and clinical course of spasticity is essential for the effective management of this condition. The hypertonia initially results from increased excitability of the alpha motor neurones due to an imbalance between the excitatory and inhibitory influences of the vestibulospinal and reticulospinal tracts. This is the 'neural component' of muscle hypertonia. However, usually within 3-4 weeks, changes in the structure and mechanical properties of the paralysed muscles and the effect of thixotropy also contribute to the hypertonia. The selection of the optimal treatment option is often influenced by whether the neural or the non-neural component is more pronounced. Muscle spasticity often interferes with motor function or causes distressing symptoms, such as painful muscle spasms. If untreated, spasticity may also lead to soft tissue shortening (fixed contractures). However, spasticity can also be beneficial to patients. For example, despite severe leg muscle weakness, most hemiplegic patients are able to walk because the spasticity of the extensor muscles braces the lower limb in a rigid pillar. Other reported benefits of spasticity include the maintenance of muscle bulk and bone mineral density and possibly a reduced risk of lower limb deep vein thrombosis. Several factors, such as skin pressure sores, faecal impaction, urinary tract infections and stones in the urinary bladder, can aggravate muscle spasticity. These factors should always be looked for as their adequate treatment is often sufficient to reduce muscle tone without the need for specific antispasticity medication. Therefore, a careful evaluation of the patient's symptoms and their impact on function, and the setting of clear and realistic therapy goals are important prerequisites to treatment. The best treatment outcomes are usually achieved when pharmacological and non-pharmacological treatment modalities are used in tandem. Different drugs are available for the management of spasticity, including oral muscle relaxants, anticonvulsant drugs, intrathecal baclofen, cannabis extract, phenol and alcohol (for peripheral nerve blocks) and botulinum toxin injections. Similarly, there is a range of non-pharmacological methods of treatment, e.g. regular muscle stretching, the use of splints and orthoses, electrical stimulation, etc. Although these are not discussed here, this should not detract from the importance of combining them with antispasticity drugs in order to maximize the clinical benefit of treatment.

Moyens non pharmacologiques et douleurs : quelle égalité d’accès pour les patients ?

Within the scope of treating patients suffering from orofacial pain, as for all patients with chronic pain, the question of the role of non-pharmacological methods arises. Their use has been recommended in the programme of the fight against pain 2006–2010. The assessment of this programme highlights the lack of development and evaluation of these methods, which are nevertheless favoured by patients and the value of which is recognised by health professionals. This article aims to provide an update on the developments of these practices in the patient’s journey, on the difficulties which remain to date, in order that they be more widely offered and that all patients may benefit from equal access to non-pharmacological methods of prevention and treatment that their condition requires. More broadly, this article invites health professionals to reflect on the value that they give them, the place that they grant them in their practice, and to the representations that they have. It also aims to identify job opportunities, particularly for pain specialist nurses, in order to promote their development.

Behavioral treatment of insomnia: a proposal for a stepped-care approach to promote public health.

Chronic insomnia is a highly prevalent condition that has psychological and medical consequences for those who suffer from it and financial consequences for both the individual and society. In spite of the fact that nonpharmacologic treatment methods have been developed and shown to be as or more effective than medication for chronic insomnia, these methods remain greatly underutilized due to an absence of properly trained therapists and a general failure in dissemination. A stepped-care model implemented in a primary-care setting offers a public health solution to the problem of treatment accessibility and delivery of behavioral treatments for insomnia. Such a model would provide graduated levels of cognitive behavioral intervention, with corresponding increases in intensity and cost, including self-help, manualized group treatment, brief individual treatment, and finally, individualized behavioral treatment provided by a specialist. To provide such a systematic approach, future research would need to confirm several aspects of the model, and a cadre of professionals would need to be trained to administer manualized care in both group and individualized formats.

Apathy After Traumatic Brain Injury: An Overview of the Current State of Play

AbstractApathy is a decrease in behavioural, cognitive and emotional components of goal-directed behaviour. Clinically, it is characterised by diminished initiation, reduced concern, and decreased activity. Apathy is a common occurrence following traumatic brain injury (TBI), occurring in around 60% of people. Consequences are widespread, negatively impacting independence, social integration, rehabilitation outcome, vocational outcome, coping and caregiver burden. The current knowledge base on apathy following TBI is presented, with implications for clinical practice. This includes a review of clinical presentations, neuroanatomical and neurochemical substrates associated with apathy, and differential diagnoses. Instruments to measure apathy are presented, highlighting those with demonstrated reliability and validity for the TBI population. Current evidence for pharmacological and non-pharmacological methods of treatment is described, with a model for non-pharmacological interventions provided and discussion of challenges faced by clinicians when treating the patient with apathy. In the TBI arena, greater understanding of apathy and methods of treatment is pivotal given the frequency of occurrence and widespread negative consequences.

Prevention of neural hypersensitivity after acute upper limb burns: Development and pilot of a cortical training protocol

Background Acute burn patients suffer pain and secondary hyperalgesia. This alters movement patterns and impairs function. Non-pharmacological methods of treatment are limited and lack rigorous testing and evidence for use. The treatment in this case series was designed to direct conscious attention to, and normalise sensation of, the injured limb in pain free way. The aim of the study was to describe a cortical training programme (CTP) in acute upper limb burn patients and to investigate the efficacy, safety and feasibility of the protocol. Method The study is a descriptive case series ( n = 6). Study tasks engaged sensory and motor nerves to influence the perception of the injured area. Visual and tactile inputs to maintain and, or normalise the homuncular map were central to the intervention. Results One patient, who commenced the study without resting pain, responded negatively. The remaining five patients had reduced pain and fear avoidance behaviours with associated improvement in arm function. Conclusions The CTP approach is safe and feasible for use with acute burn patients where pain is reported at rest. Comparative studies are required to determine the relative efficacy of the program to usual interventions and the patients who may benefit from the technique.

Factors Influencing Physical Activity Behavior among Iranian Women with Type 2 Diabetes Using the Extended Theory of Reasoned Action.

BackgroundFindings of most studies indicate that the only way to control diabetes and prevent its debilitating effects is through the continuous performance of self-care behaviors. Physical activity is a non-pharmacological method of diabetes treatment and because of its positive effects on diabetic patients, it is being increasingly considered by researchers and practitioners. This study aimed at determining factors influencing physical activity among diabetic women in Iran, using the extended theory of reasoned action in Iran.MethodsA sample of 352 women with type 2 diabetes, referring to a Diabetes Clinic in Khoy, Iran, participated in the study. Appropriate instruments were designed to measure the desired variables (knowledge of diabetes, personal beliefs, subjective norms, perceived self-efficacy, behavioral intention and physical activity behavior). The reliability and validity of the instruments were examined and approved. Statistical analyses of the study were conducted by inferential statistical techniques (independent t-test, correlations and regressions) using the SPSS package.ResultsThe findings of this investigation indicated that among the constructs of the model, self efficacy was the strongest predictor of intentions among women with type 2 diabetes and both directly and indirectly affected physical activity. In addition to self efficacy, diabetic patients' physical activity also was influenced by other variables of the model and sociodemographic factors.ConclusionOur findings suggest that the high ability of the theory of reasoned action extended by self-efficacy in forecasting and explaining physical activity can be a base for educational intervention. Educational interventions based on the proposed model are necessary for improving diabetics' physical activity behavior and controlling disease.

Treatment of pathological gambling

This paper highlights the development of pharmacological and nonpharmacological treatments for pathological gambling and is based on a review of the literature published in the past 12 months. The efficacy of naltrexone treatment for pathological gambling has been replicated in a double-blind, placebo-controlled, confirmatory study. For mood stabilizers, whereas carbamazepine and topiramate continued to produce positive results, olanzapine failed to show superior outcomes compared with placebo control. Two new pharmacological agents for pathological gambling, N-acetyl cysteine and modafinil, produced significant improvement for pathological gamblers. Several studies examined the outcomes of nonpharmacological treatments. Recent studies showed that cognitive-behavioral therapy failed to produce superior outcomes compared with other less costly methods such as brief interventions. Two new nonpharmacological treatment methods have been reported, including the use of videoconferencing in delivering ongoing supervisions after exposure therapy and the congruence couple therapy, which aims to heal the person as a system whole. Recent treatment outcomes studies address not only the effectiveness, but also the efficacy of different treatment approaches. Results of two meta-analysis studies showed that nonpharmacological treatments have a larger overall effect size than pharmacological treatments; however, owing to the diversity in study designs, it is unclear whether nonpharmacological treatments are more effective than pharmacological treatments at this point.

Compliance, concordance, adherence

The referral letter was brief and to the point: ‘This 81-year-old lady's heart failure is getting worse, with increasing peripheral oedema, despite maximal doses of a wide range of medications, listed below. Please advise.’ The problem turned out to be very simple, as her daughter explained when she brought her to the clinic. ‘She won't take the water tablets, doctor,’ she told me. Her mother liked to take a stroll outside in the mornings and stay indoors in the afternoons to watch her favourite television programmes. The morning diuresis made that impossible. And since her heart failure had become worse the daily strolls had become more difficult as well. I suggested that she take the furosemide in the afternoons instead.

P4-128: Physical training a non pharmacological method of treatment in P.D. patients

P4-128: Physical training a non pharmacological method of treatment in P.D. patients

Treatment options for migraine during pregnancy

Migraine and pregnancy commonly co-exist and healthcare providers should be ready to give advice to women with migraine regarding treatment options that are compatible with pregnancy and lactation. A major goal of treatment is to avoid medications that may be harmful to the developing fetus or cause other pregnancy problems. Nonpharmacological behavioral methods of treatment are especially useful in pregnancy. Migraine increases the risk of pregnancy-related stroke and pre-eclampsia and women with migraine should be monitored for these problems.

Behavioral Treatment for Chronic Insomnia Works

Chronic insomnia, whether primary or associated with comorbid medical or psychiatric conditions, is a prevalent and disabling condition that increases with age. This past year, researchers have continued to document the efficacy of nonpharmacologic treatment methods and the potential adverse effects of chronic use of hypnotics in elderly individuals. These results are important in light of the infrequent use of behavioral methods to treat insomnia, coupled with the accelerating rate of hypnotic use in the U.S. population, especially in the elderly. Two placebo-controlled, randomized trials examined the relative efficacy of cognitive-behavioral therapies, hypnotic medications, and pill placebo in treating primary chronic insomnia. One study also included an arm in which patients received both CBT and a …

Die Depression in der Postpartalzeit: eine diagnostische und therapeutische Herausforderung

Postpartum is not a specific entity. There is neither a very specific psychopathology nor evidence for a specific aetiology. The prevalence of severe is not significantly enhanced in the year as compared to women of the same age group without delivery who have quite a high prevalence of anyway. Incidence of milder might slightly be enhanced in the first weeks. Giving birth and adapting to the new mother role seem to be stressors contributing to the outbreak of in vulnerable, predisposed women or to enhance pre-existing depression. Biological, especially hormonal, as well as psychosocial factors can be relevant stressors in this situation. Although this is not a specific entity, the diagnostic term or specifier postpartum depression might still be justified, as in early motherhood shows many important specifities. Diagnosis is especially difficult, as women, due to shame, stigma and many fears, do not seek help and doctors, due to misinterpretation of symptoms, often do not recognise the severity of the situation. Untreated, these disorders can have especially severe consequences, not only for the mother, but also for the child and the whole family. These disorders therefore need our special attention and special treatment. This means modifications of our pharmacological, non-pharmacological and psychotherapeutic treatment methods. Therapy - although in principle the same as that of other depressive disorders - has to put a special emphasis on the needs of the period. Education about the fact that this is a disease and not due to failure as a mother is of utmost importance to relieve the patients from feelings of guilt. Counselling and practical advice for the mother and her family is often needed as well as the help of a midwife, a family nurse, a social worker and/or other health care professionals. A good mother-infant bonding should be a main concern from the start. This means that the mother should not be separated from her infant for longer periods of time. However, she needs a lot of help in order to allow for relaxed contacts with the infant. Pharmacological treatment is often complicated by the patient's desire to breast-feed, yet there are no controlled trials of antidepressant treatment during lactation as regards the potential side effects and/or long-term consequences for the infant. On the other hand, the risks of ongoing severe are generally regarded as higher than the potential risks of medication. Thus, if a mother insists on breast-feeding, she has to be educated about side effects and the baby has to be carefully monitored. Several studies have in the meantime also shown positive effects of oestrogen substitution and non-pharmacological treatments such as bright-light therapy. Psychotherapy should be initiated as soon as possible and be very supportive in the beginning. Specific manualised forms of psychotherapy for women with have also shown very promising results. In the future, more emphasis should be laid on prophylaxis, specific education and the broad implementation of low-threshold services. Under all circumstances, special attention must be given to the mother-child-relationship, on the one hand to reduce feelings of guilt in the mother and thereby to enhance the process of healing, on the other hand to prevent traumatisation of the infant and to avoid deleterious long-term consequences.

Acupressure and the prevention of nausea and vomiting after laparoscopy

The efficacy of currently available antiemetics remains poor. Concern with their side effects and the high cost of the newer drugs has led to renewed interest in non-pharmacological methods of treatment. We have studied the efficacy of acupressure at the P6 point in the prevention of nausea and vomiting after laparoscopy, in a double-blind, randomized, controlled study of acupressure vs placebo. We studied 104 patients undergoing laparoscopy and dye investigation. The anaesthetic technique and postoperative analgesia were standardized. Failure of treatment was defined as the occurrence of nausea and/or vomiting within the first 24 h after anaesthesia. The use of acupressure reduced the incidence of nausea or vomiting from 42% to 19% compared with placebo, with an adjusted risk ratio of 0.24 (95% CI 0.08-0.62; P = 0.005). Other variables were similar between groups.

Advantages and limitations of the concept of antidepressant therapy

The current availability of a range of effective treatments make it more than ever necessary for depression to be recognised. The emphasis of treatment has moved from acute episodes to the longitudinal course of affective disorders. In addition to Major Depressive Disorder, the need for treatment is now established in less severe variants, particularly Dysthymia; the same drugs are applicable, but should be part of a global strategy. In general, antidepressants have to be considered in relation to non-pharmacological treatment methods, of which the most important is ECT. A great variety of new drugs have been found to have antidepressant efficacy, but pharmacologically this action is not a specific or exclusive one. Side-effects have on the whole not been studied for long enough, or in depressed patients rather than healthy volunteers; there are marked variations between individuals in their reactions to different drugs. Co-morbidity is a frequent issue in the treatment of depression, particularly for the elderly. Since overall suicide rates have not fallen in many countries, the treatment particularly of Major Depressive Disorder and Bipolar Disorder needs to be strengthened.

Systemic antimicrobial treatment of foot infections in diabetic patients.

The pathophysiology, microbiology, and treatment of diabetic foot infections are reviewed. Patients with diabetes mellitus are at risk for developing infections of the lower extremity because of physiological and anatomical changes. The treatment must be aggressive to prevent systemic complications and recurrence. A combination of pathogens is likely to be found at the site of infection, including gram-negative and gram-positive aerobes as well as anaerobes. If preventive and nonpharmacologic treatment methods are not successful, systemic antimicrobial therapy is indicated. The appropriate agent for empirical therapy is chosen on the basis of the patient's medical history and clinical status with consideration to cost and administration issues. Until a specific organism is identified, a single broad-spectrum agent is administered. The duration of i.v. therapy and appropriate role for oral administration is based upon clinical response. Home infusion therapy is an option for medically stable patients. A single, broad-spectrum, i.v. antimicrobial is usually the best choice for empirical treatment of diabetic foot infection. The regimen is then tailored on the basis of the clinical response and culture and susceptibility test results. Aggressive pharmacologic and nonpharmacologic treatment is needed to avoid possible gangrene and loss of limb.

Practical guidelines for the treatment of behavioural complications of dementia.

A step-by-step approach to management of behavioural problems in dementia is outlined. Initial strategies include assessment of the underlying cause and consideration of non-pharmacological methods of treatment. If pharmacotherapy is required, the altered pharmacokinetics in the elderly and the variable efficacy of different psychotropic drugs should be kept in mind. Recommendations regarding drug dosage, monitoring and review are given.

Chronic pain

Management of chronic pain is not a simple task. Pain is a complex, multifaceted perceptual experience. For effective management, the physician needs the patient's cooperation and personal commitment. Many chronic pain patients become preoccupied with their pain and gradually lose interest in social activities, or they may use their pain to avoid anxiety-producing situations. Chronic pain therapy instituted by the primary care physician demands a coordinated approach using pharmacologic and nonpharmacologic treatment methods. When necessary, appropriate treatment by subspecialty physicians and by psychologists and other paramedical personnel should be coordinated.

Treatment of Low-Back Pain

To the Editor.— The article by Dr Richard A. Deyo1reviews a number of trials of treatment for low-back pain, including our multicenter trial2of physiotherapy in the management of sciatic symptoms. Dr Deyo's assessment of the trials under consideration involved a number of assumptions and arbitrary decisions that, coupled with the omission of any mention of one of its central features, have given a misleading impression of our trial. First, Dr Deyo implies that assessment of outcome in our trial was not blind. It is, of course, almost impossible to ensure blind assessments in trials of nonpharmacologic treatment methods. In our trial, the assessments of progress used in the analyses were made by the patients and not by the therapists. Dr Deyo's comment that the observers in our trial were not blind is, therefore, irrelevant. Second, Dr Deyo says that our descriptions of the exercises and of