Single Treatment Approach Research Articles

Effects of tailored neck-shoulder pain treatment based on a decision model guided by clinical assessments and standardized functional tests. A study protocol of a randomized controlled trial

BackgroundA major problem with rehabilitation interventions for neck pain is that the condition may have multiple causes, thus a single treatment approach is seldom efficient. The present study protocol outlines a single blinded randomised controlled trial evaluating the effect of tailored treatment for neck-shoulder pain. The treatment is based on a decision model guided by standardized clinical assessment and functional tests with cut-off values. Our main hypothesis is that the tailored treatment has better short, intermediate and long-term effects than either non-tailored treatment or treatment-as-usual (TAU) on pain and function. We sub-sequentially hypothesize that tailored and non-tailored treatment both have better effect than TAU.Methods/Design120 working women with minimum six weeks of nonspecific neck-shoulder pain aged 20–65, are allocated by minimisation with the factors age, duration of pain, pain intensity and disability in to the groups tailored treatment (T), non-tailored treatment (NT) or treatment-as-usual (TAU). Treatment is given to the groups T and NT for 11 weeks (27 sessions evenly distributed). An extensive presentation of the tests and treatment decision model is provided. The main treatment components are manual therapy, cranio-cervical flexion exercise and strength training, EMG-biofeedback training, treatment for cervicogenic headache, neck motor control training. A decision algorithm based on the baseline assessment determines the treatment components given to each participant of T- and NT-groups. Primary outcome measures are physical functioning (Neck Disability Index) and average pain intensity last week (Numeric Rating Scale). Secondary outcomes are general improvement (Patient Global Impression of Change scale), symptoms (Profile Fitness Mapping neck questionnaire), capacity to work in the last 6 weeks (quality and quantity) and pressure pain threshold of m. trapezius. Primary and secondary outcomes will be reported for each group with effect size and its precision.DiscussionWe have chosen not to include women with psychological ill-health and focus on biomedical aspects of neck pain. Future studies should aim at including psychosocial aspects in a widened treatment decision model. No important adverse events or side-effects are expected.Trial registrationCurrent Controlled Trials registration ISRCTN49348025.

Factors associated with major infections in patients with granulomatosis with polyangiitis and systemic lupus erythematosus treated for deep organ involvement

This study is an audit and a comparison of major infective complications in patients with granulomatosis with polyangiitis (GPA) and systemic lupus erythematosis (SLE). Data were collected on consecutive patients attending a single treatment approach, multidisciplinary vasculitis centre who met diagnostic criteria for GPA and SLE from 01/01/2006 to 30/06/2006. Immunosuppressive treatment is used in this clinic with guidelines targeting avoidance of neutropenia. For each patient, documentation was made of disease presentation, organ involvement and therapy used. A history of major infections requiring hospital admission and intravenous antimicrobials pre- and post-diagnosis was recorded. Patients with GPA received a higher cumulative dose of cyclophosphamide, had a higher median age, shorter period of follow-up and had lower mean and nadir absolute lymphocyte counts and nadir neutrophil counts. GPA patients had more major infections per patient years (P = 0.0027) and respiratory tract infections (P = 0.0031) per patient years. Relative risk (RR) of major infection was significantly increased with methylprednisolone, RR 11.1 (P = <0.0001), cyclophosphamide, RR 2.0 (P = 0.0246) and the intensive phase of treatment, RR 13.3 (P = <0.0001). Marked lymphopenia was common in both groups during follow-up and was associated with an increased risk of major infection (P = 0.0020). Major infections, in particular respiratory tract infections, are more common in those treated for GPA than SLE. This may be due to a combination of factors including greater doses and duration of methyprednisolone and cyclophosphamide. We recommend treatment strategies that aim not only to avoid neutropenia but that also identify lymphopenia as a risk factor for major infection.

Complex Regional Pain Syndrome Type-I: Social Aspect And Life Care Planning

Complex regional pain syndrome type I, also known as reflex sympathetic dystrophy, is a multisymptom syndrome usually affecting one or more extremities. Etiology is not being solved completely, but uncontrolled sympathetic activity and inflammatory response following soft tissue and nevre injury is thought to be the main cause of this disease. Common symptoms are pain and tenderness to palpation and evidence of autonomic nervous dysfunction in an extremity. There is not one single successfull treatment approach to complex regional pain syndrome and if the treatment of patient is not enough, major problems in patients social life may be occured. In this study, social aspect and life care planning of complex regional pain syndrome type I were discussed.

Analysis of Factors Influencing Outcome in Patients With In-Transit Malignant Melanoma Undergoing Isolated Limb Perfusion Using Modern Treatment Parameters

PURPOSE In-transit disease afflicts approximately 10% of patients with extremity melanoma; no single treatment approach has been uniformly accepted as the most effective. We report long-term outcomes in patients with in-transit extremity melanoma who underwent isolated limb perfusion (ILP) in an era of increasingly accurate staging, uniform operative and treatment conditions, and regular long-term follow-up. PATIENTS AND METHODS Between May 1992 and February 2005, 91 patients (median age, 57 years; 50 women, 41 men) underwent a 90-minute hyperthermic ILP (melphalan, 10 to 13 mg/L limb volume, tumor necrosis factor [TNF; n = 44], or interferon [n = 38]) using uniform operative technique and intraoperative leak monitoring. Patients were prospectively followed for response, in-field progression-free survival (PFS), and overall survival (OS). Parameters associated with in-field PFS and OS were analyzed by standard statistical methods. Results There was one operative death (1.1%). There were 62 complete responses (69%) and 23 partial responses (26%) in 90 assessable patients. At a median potential follow-up of 11 years, median in-field PFS was 12.4 months and median OS was 47.4 months; 5 and 10-year actuarial OS probabilities were 43% and 34%, respectively. Female sex and low tumor burden (< or = 20 lesions) were associated with prolonged in-field PFS (male:female hazard ratio [HR], 2.07; 95% CI, 1.27 to 3.38; 21+ v < or = 20 tumors HR, 2.29; 95% CI, 1.21 to 4.34; P < .011 for both). Female sex was associated with improved OS (P = .027; male:female HR, 1.82; 95% CI, 1.07 to 3.09). CONCLUSION In appropriately selected patients, ILP has clinical benefit. The use of TNF was not associated with improved in-field PFS, while female sex was associated with better survival.

Integrative Practice: Presentation of an Inpatient Family Therapy Program

ABSTRACT An inpatient family therapy program for treating complex combinations of individual, couple, and family problems is presented within a holistic treatment framework. The treatment context and scheduled program form treatment guidelines, yet the single case treatment approach may be tailored. A case vignette illustrates how theories and methods from both the individual and systemic therapy traditions are implemented as integrative practice, enabling synergistic effects. The treatment program is evaluated throughout the therapy and at follow-up. Consumer satisfaction results show that the clients were very pleased with the treatment at discharge, and this satisfaction was maintained at 1-year follow-up.

Comparable efficacy and safety of treatment with biological agents etanercept and anakinra in children with Juvenile Idiopathic Arthritis in Latvia

Background The introduction of biologics holds great promise in the management of the two, often most aggressive and challenging forms of Juvenile Idiopathic Arthritis (JIA) – polyarticular and systemic onset or Still`s disease. JIA is not a single disease and treatment approach varies between types. Recently it has been demonstrated that treatment with anti TNF agent etanercept has a major beneficial effect on children with refractory polyarthritis [1]. Since IL-1 has been shown to be an important cytokine in the pathogenesis of systemic arthritis, therapies directed against this cytokine has been shown to be effective for this form of JIA [2]. Objectives To evaluate treatment efficacy and safety with two different biologics: anti TNF etanercept and anti IL-1 anakinra in patients with polyarthritis and Still`s disease. Methods and materials Data from 32 JIA patients (30 serenegative polyarthritis and 2 Still`s disease), aged 4 to 18 years, receiving treatment with biological agents, were obtained. JIA diagnosis and disease type were confirmed according to the ILAR classification criteria of JIA [3]. Patients unresponsive to prior MTX therapy, were started with combination etanercept (s/c twice a week in a dose 0.4 mg/kg) and methotrexate (MTX) (once a week in a dose 10-15 mg/m 2) with the evaluation of clinical response at the period of 3 and 6 months. The assesment of therapeutical response was made using criteria of preliminary definition of improvement in JIA proposed by Giannini et al. [4]. Results One patient with polyarthritis showed intolerance to etanercept, due to which the drug was discontinued, while 29 patients with polyarticular JIA (14 boys and 15 girls) showed improvement after the combination etanercept and MTX treatment, according to the global physician assesment of the severity of disease (p<0.01), the global assesment of overall well-being determined by the parent (p<0.01) and by the pain severity scale (p<0.01). Due to the lack of response to etanercept in 2 pts with systemic arthritis, treatment was switched to anakinra (in combination with MTX), which showed good therapeutic response and remission was achieved. The clinical and laboratory evaluation of the patients showed decrease in the number of affected joints and decrease in CRP level (p<0.05). Overall in our experience treatment with biologics, except for mild local injection site reactions in some patients, was not connected with the occurence of any severe side effects, opportunistic infections or autoimmune reactions. Conclusions 1) Anti TNF treatment is effective in patients with polyarticular course of JIA, resistant to MTX therapy 2) Patients with systemic arthritis who fail to respond to anti TNF, are improving on anti IL-1 treatment with anakinra, that is according to the literature data 3) Treatment with biologics shows good safety profile 4) The use of the Biologics Registry data is essential to establish the longer-term clinical effectiveness of biologics, as well as their potential for toxicity to help further define the most appropriate use of these agents.

Principles and Clinical Application of Schema Therapy for Patients with Borderline Personality Disorder

Many approaches for treatment are proposed for Borderline Personality Disorder, but there is no single treatment approach that seems to be the treatment of choice. New approaches are emerging and during the past ten years several cognitive behavioural oriented therapies have been developed for the treatment of persons with Borderline Personality Disorder. The article presents some essential features of the most recent and integrative cognitive approach for patients with Borderline Personality Disorder, namely Schema therapy developed by Young and colleagues. Principles and application of Schema therapy are illustrated by clinical vignettes based on the authors’ own clinical work with these patients.

A Critical Reconsideration of the Clinical Effects and Treatment Recommendations for Sodium Channel Blocking Drug Cardiotoxicity

The cardiac sodium channel is comprised of proteins that span the cardiac cell membrane and form the channel pore. Depolarisation causes the proteins to move and open the sodium channel. Once the channel is open (active conformation), sodium ions move into the cell. The channel then changes from the active conformation to an inactive conformation - the channel remains open, but influx of sodium ions ceases. Recovery occurs as the channel moves from the inactive conformation back to the closed conformation and is then ready to open following the next depolarisation. Sodium channel blocking drugs (NCBDs) occupy receptors in the channel during the active and inactive conformations. The drug dissociates from most of the channel receptors during recovery, but the time it takes the drug to dissociate slows recovery. The slowed recovery prolongs conduction time, the main toxicity of NCBD overdose. Conduction time is further prolonged if heart rate increases as there are more available active and inactive conformations/unit time, which increases channel receptor binding sites for the NCBD. In addition to prolonging conduction time, NCBDs also decrease inotropy. Treatment of NCBD cardiotoxicity has been based on in vitro and animal experiments, and case reports. Assumptions based on this evidence must now be reassessed. For example, canines consistently develop ventricular tachycardia (VT) when tricyclic antidepressants (TCAs) are administered. Much of the literature discussing NCBD cardiotoxicity assumes that TCA poisoning induces VT in humans with the same regularity that occurs in canines. Seemingly, in support of this assumption was the finding that patients with remote myocardial infarction developed VT when therapeutically ingesting a NCBD. However, conduction is prolonged in myocardium that is or has been ischaemic. NCBD prolong conduction more in previously ischaemic myocardium than in normal myocardium, which causes nonuniform conduction and allows the development of re-entrant arrhythmias such as VT. Although some nonuniform conduction may occur in the healthy heart following a NCBD overdose, there is no evidence that nonuniform conduction occurs to the extent that it will cause re-entrant arrhythmias in this setting. Using various animal models and a variety of NCBDs, sodium ions, bicarbonate ions and alkalosis have been compared for the treatment of ventricular arrhythmias, hypotension and mortality. The results of these experiments have been extrapolated to NCBD overdose in humans. Animal models and single treatment approaches may have narrowed our scope. More recent evidence indicates that properties of each individual NCBD may require unique treatment. There is limited evidence that glucagon, which increases initial sodium ion influx into the cardiac cell, should be considered early in the treatment of cardiotoxicity. Another consideration may be treatment of NCBD with faster kinetics. Conduction time is decreased if a NCBD occupying the receptor is replaced by a NCBD that moves off and on the receptor more quickly. There is less evidence for this treatment, as risk may be greater. With greater understanding of the sodium channel and NCBDs, we must reassess our approach to the treatment of patients with healthy hearts who overdose on NCBD.

Single Treatment Approaches to Benign paroxysmal Positional Vertigo, Is It Enough?

Bening paroxysmal positional vertigo (B.P.P.V) is one of the most common vestibular disorders.During the last years, it has been attributed to cupulolithiasis or canalithiasis of the posterior semicircular canal.This randomized study was done to determine the effectiveness of two different physical therapy approaches and to determine if a single treatment approaches is enough.In this prospective study 80 patients received either a single treatment based on the hypothesis that the vertigo and nystagmus of (B.P.P.V) are due to debris adhering to the cupula of posterior semicircular canal (cupulolithiasis), Semont maneuver, or a single treatment based on the hypothesis that the debris is free floating in the long arm of the posterior semicircular canal (canalithiasis), Epley maneuver.Treatment outcome was classified as asymptomatic, improved and no change. Analysis of the results of this study revealed that at the end of the first session , out of 80 patients, 60(75%) were asymptomatic ; 14(18%) improved ;6(7%) showed no change. Follow– up showed that 8 patients developed recurrence. After a second session to 22 patients (8 recurrences, 10 improved, 4 had no change) ,17 became asymptomatic.This means that at the end of the seconed session ,69 (86%) of 80 patients became asymptomatic ; 9(11%) of 80 patients improved ; 2(3%) of 80 patients showed no change. In conclusion , this study shows that 1) The success rate of Semont’s maneuver was up to 80%, so it is much better than Epley maneuver 70% after the first session. 2)Recurrent cases are best treated with second session.

Single Treatment Approaches to Benign paroxysmal Positional Vertigo, Is It Enough?

Bening paroxysmal positional vertigo (B.P.P.V) is one of the most common vestibular disorders.During the last years, it has been attributed to cupulolithiasis or canalithiasis of the posterior semicircular canal.This randomized study was done to determine the effectiveness of two different physical therapy approaches and to determine if a single treatment approaches is enough.In this prospective study 80 patients received either a single treatment based on the hypothesis that the vertigo and nystagmus of (B.P.P.V) are due to debris adhering to the cupula of posterior semicircular canal (cupulolithiasis), Semont maneuver, or a single treatment based on the hypothesis that the debris is free floating in the long arm of the posterior semicircular canal (canalithiasis), Epley maneuver.Treatment outcome was classified as asymptomatic, improved and no change. Analysis of the results of this study revealed that at the end of the first session , out of 80 patients, 60(75%) were asymptomatic ; 14(18%) improved ;6(7%) showed no change. Follow– up showed that 8 patients developed recurrence. After a second session to 22 patients (8 recurrences, 10 improved, 4 had no change) ,17 became asymptomatic.This means that at the end of the seconed session ,69 (86%) of 80 patients became asymptomatic ; 9(11%) of 80 patients improved ; 2(3%) of 80 patients showed no change. In conclusion , this study shows that 1) The success rate of Semont’s maneuver was up to 80%, so it is much better than Epley maneuver 70% after the first session. 2)Recurrent cases are best treated with second session.

Diagnosis and Management of Trichotillomania in Children and Adolescents

Trichotillomania (TTM), a disorder characterized by the repeated non-cosmetic pulling out of hair from any part of the body, was first described in 1889. The disorder can be associated with serious social and psychologic dysfunction, as well as medical problems. A large proportion of the published scientific literature on TTM consists of case reports, and the disorder has only received significant clinical and research attention over the last 20 years. The disorder occurs across age groups and tends to follow a chronic course in the majority of cases. There is evidence for a bimodal onset, with peaks in the pre-school years and in early adolescence. TTM in child and adolescent populations has not been extensively studied, and the etiology, natural course, and best treatment approaches for the disorder are not known. Assessment for TTM in children and adolescents focuses on making the diagnosis and documenting the response to treatment. Despite the lack of validity studies in child and adolescent populations, most assessments for TTM use one or more formal TTM measures. Although classified as an impulse control disorder in the Diagnostic and Statistical Manual of Mental Disorders (4th Edition), there is some controversy about making the diagnosis in child populations because of criteria B (pattern of rising tension prior to pulling) and C (relief after pulling). There is no consensus for the treatment of TTM in children and adolescents. As in adults, a variety of interventions have been reported, including dynamic therapy, behavioral therapy, and psychopharmacology. Use of pharmacologic interventions in the pre-school age group is rare, but becomes more common as the child ages into adolescence. The most frequently used agents include clomipramine, fluoxetine, and paroxetine. The effectiveness of psychopharmacologic interventions for TTM in children and adolescents is, at best, mixed. A multiple modal approach that includes behavioral, pharmacologic, and other therapies may be the best strategy. There have been no controlled treatment trials in child and adolescent populations. Case reports favor a behavioral approach as the first-line single modality of treatment. Controlled studies of single modalities and combined treatment approaches are clearly needed.

Individual Behavioral Profiles and Predictors of Treatment Effectiveness for Children With Autism.

Differential responsiveness to intervention programs suggests the inadequacy of a single treatment approach for all children with autism. One method for reducing outcome variability is to identify participant characteristics associated with different outcomes for a specific intervention. In this investigation, an analysis of archival data yielded 2 distinct behavioral profiles for responders and nonresponders to a widely used behavioral intervention, pivotal response training (PRT). In a prospective study, these profiles were used to select 6 children (3 predicted responders and 3 predicted nonresponders) who received PRT. Children with pretreatment responder profiles evidenced positive changes on a range of outcome variables. Children with pretreatment nonresponder profiles did not exhibit improvements. These results offer promise for the development of individualized treatment protocols for children with autism.

Adolescents' and Young Adults' Perspectives on a Continuum of Care in a Three Year Drug Treatment Program

Recent discussion in the adolescent treatment community has centered on the therapeutic merits of continuum of care treatment for adolescent and young adult substance abusing populations. However, despite this discussion, few studies to date have actually looked at how adolescents and young adults view continuum of care treatment in practice. In this paper a continuum of care offered within a single treatment approach will be addressed from the perspectives of youths participating in treatment at a three year step-down therapeutic community program with four distinct levels of care: residential treatment, intensive day treatment, day treatment with work/school release, and ambulatory meetings. Adolescents and young adults attending this program must complete all four levels of care before they are eligible for program graduation. Data from 53 qualitative semistructured and open-ended interviews (conducted with 45 adolescents and young adults) indicate that treatment experiences were marked by significant program transition points, during which clients stepped down from one level of care to another. Adolescents and young adults reported experiencing distress at and during these transition points. However, they also indicated that overall emotional and psychological stress was minimized due to the following: (1) these transitions were experienced within a single program structure, (2) youths transitioned through a continuum of care with program peers and friends, and (3) the program staff was perceived by adolescents and young adults to be compassionate and encouraging.

High energy devices versus low energy devices in orthopedics treatment modalities

The orthopedic consensus group defined in 1997 the 42 most likely relevant parameters of orthopedic shock wave devices. The idea of this approach was to correlate the different clinical outcomes with the physical properties of the different devices with respect to their acoustical waves. Several changes in the hypothesis of the dose effect relationship have been noticed since the first orthopedic treatments. The relation started with the maximum pressure p+, followed by the total energy, the energy density; and finally the single treatment approach using high, and then the multiple treatment method using low energy. Motivated by the reimbursement situation in Germany some manufacturers began to redefine high and low energy devices independent of the treatment modality. The OssaTron as a high energy, single treatment electro hydraulic device gained FDA approval as the first orthopedic ESWT device for plantar fasciitis and, more recently, for lateral epicondylitis. Two low energy devices have now also gained FDA approval based upon a single treatment. Comparing the acoustic data, differences between the OssaTron and the other devices are obvious and will be elaborated upon. Cluster analysis of the outcomes and the acoustical data are presented and new concepts will be suggested.

A single pasture limited treatment approach to estimate production loss from gastrointestinal nematodes in grazing stocker cattle

The objective of this study was to evaluate the use of a single pasture, limited treatment methodology to assess the impact of gastrointestinal nematodes on weight gain in grazing cattle. From a group of 450 British crossbred, yearling spayed heifers, 60 animals were randomly selected (prospective randomization) prior to placement on summer pasture. Each of these 60 animals was weighed, a fecal sample obtained for nematode egg count and a uniquely numbered ear tag applied. A randomly assigned group of 30 received treatment with one ivermectin sustained release bolus, while the remaining 30 served as non-treated controls. The treatment and control groups rejoined the remaining non-treated 390 animals, and were grazed as a single group for 165 days. At grazing conclusion, treatment and control cattle were individually weighed, and fecal samples obtained for nematode egg counts. Treatment was associated with a 0.064 kg per grazing day gain increase, or a 10 kg increase over the grazing season ( P=0.02). Nematode egg counts at grazing initiation were not different between treatment and control ( P=0.30), though egg counts in treated cattle at study end were lower than control ( P<0.0001). Results of this study support the use of a single pasture limited treatment approach for measuring the effect that internal nematodes have on weight gain in grazing cattle under commercial range conditions.

Current concepts and controversies in the diagnosis and treatment of attention deficit hyperactivity disorder.

Concerns about possible over-diagnosis and over-treatment of attention deficit hyperactivity disorder (ADHD) have been prominent in media reports, as have various competing claims about the safety and efficacy of the various treatments for ADHD. Drawing upon the results of the recent National Institutes of Health Consensus Conference, this paper reviews the evidence concerning these controversial areas. Although there do appear to be pockets of over-prescribing in selected communities, the best available evidence suggests that across the United States substantial underdiagnosis continues to occur, and only 50% of all children with ADHD are being treated with stimulant medications. Among those who are treated with stimulant medications, inadequate treatment is quite common. Substantial evidence suggests that for ADHD symptoms, stimulants are more effective than behavioral therapies in head-to-head comparisons. Combined medication and behavioral treatments do not offer any meaningful advantages over medication treatments alone for ADHD symptoms. For other areas of functioning, however (social skills, academic performance, etc.), combined treatments appear to offer some modest advantages over single treatment approaches. Although research findings show that ADHD can indeed be rigorously and reliably diagnosed under optimal conditions, and that carefully delivered treatments can yield substantial benefits, such best practices do not appear to be taking place in the real world. Thus, although the above controversies are facing some resolution in principal, in practice much remains to be done.

Treating Traumatized Children

This article reviews and summarizes existing research that has examined treatment outcome with traumatized children. Methodological challenges in this line of research are addressed. Additionally, there is a review of types of treatment study designs as well as the kinds of treatment that have been used with traumatized children. Treatment studies for children exposed to specific stressors—including disaster situations, school and community violence, severe medical conditions, war, sexual and physical abuse, and domestic violence—are summarized and critiqued. Major findings are that (a) no single treatment approach will likely be applicable for all traumatized children as this population presents with a diversity of emotional and behavioral difficulties, (b) research on abused children has accumulated the greatest amount of empirical treatment outcome data for traumatized children, and (c) cognitive-behavioral therapy has been demonstrated in several recent empirically sound studies to be effective in treating traumatized children. Implications from these findings for clinical practice, research, and public policy are addressed.

Benign paroxysmal positional vertigo and otolith repositioning.

It is generally agreed that BPPV results from dysfunction of the posterior semicircular canal (PSCC). The characteristic rotary nystagmus seen in BPPV can be reproduced by electrical stimulation of the PSCC and eliminated by deafferentation of the PSCC. Two theories have been advanced to explain the pathophysiological characteristics of BPPV; these are cupulolithiasis and canalithiasis. The former is Schuknecht’s original theory of a substance adherent to the cupula, while the latter presumes the presence of free-floating debris within the posterior canal. Temporal bone studies may not be able to provide sufficient evidence to differentiate between the 2 theories. Moriarty et al showed that deposits are present on all of the semicircular canal ampullae, although the PSCC is most commonly involved. Supportive evidence for the canalithiasis theory is provided by surgeons who have noted freely moving particles within the semicircular canals during the translabyrinthine approach to the cerebellopontine angle and when performing posterior canal occlusion. Regardless of whether debris is fixed or free floating, it is surmised that if the debris could be removed from the canal, the patient would be rendered free of symptoms. Noninvasive techniques for the removal of this debris have been developed. Brandt and Daroff initially reported on the use of a positioning technique for elimination of BPPV. They noted abrupt resolution of symptoms in one third of their patients. While recognizing a propensity for spontaneous resolution of symptoms, they concluded the time course of the recovery was consistent with a mechanical removal of debris and did not represent central compensation. Renewed interest in physical therapy for BPPV followed descriptions of repositioning maneuvers by Semont et al and Epley. Semont et al adhered to the theory of cupulolithiasis. Therefore, their intervention is directed at dislodging a fixed deposit from the cupula. In performing this maneuver, a patient is asked to sit on the side of an examination table with the head turned away from the affected ear. The patient is then rapidly moved to a lateral decubitus position, with the head facing the ceiling. After a few minutes, the patient is quickly sat up and then moved to the opposite lateral decubitus position without changing the orientation of the head on the body. Thus the patient is now facing the floor. The patient then sits up and is asked to remain upright for 48 hours. Epley favored the canalithiasis theory. He devised a technique to move the head in a manner that rotates the posterior canal about its central axis, bringing the ampullated end from a dependent position to its zenith. This induces gravity-directed movement of particulate matter into the vestibule, where it should not produce symptoms. The patient is initially placed in the Hallpike position with the affected ear down. While remaining in the supine position, the patient’s head is rotated to the contralateral side. Next, the body is rolled onto the contralateral shoulder with no change in head position, thus effectively rotating the head 180° from the initial position. Finally, the patient is sat upright with the chin down. A handheld oscillator is applied to the skull throughout the positioning sequence to dislodge any fixed deposits in an effort to thoroughly clear the PSCC. Once again, the patient is asked to remain upright for 48 hours after the procedure. Most subsequent studies use these techniques exactly as described by the original authors or with minor variations. Reported results are quite encouraging. The Table lists data from selected studies, grouped according to the type of intervention. For accurate comparison, only those patients with no evidence of positional vertigo on follow-up are listed as cured. Some authors use a single treatment approach, while others repeat therapeutic measures at intervals from several days to weeks. A treatment session may include a single maneuver or multiple repetitions. Is one technique better as a single treatment? In a prospective randomized From the Department of Otolaryngology, University of Texas Medical Branch, Galveston. CLINICAL CHALLENGES IN OTOLARYNGOLOGY

Psychostimulant Abuse: The Case for Combined Behavioral and Pharmacological Treatments

Behavioral and pharmacological therapies have been used alone and in combination for the treatment of substance abuse; however, to date, no single treatment approach for psychostimulant abuse has demonstrated widespread efficacy. This paper describes the various functions that are served by both behavioral therapies and pharmacotherapies and their respective mechanisms of action. It is argued that combined treatments can be expected to produce additive effects because the two approaches operate through different and potentially complementary mechanisms. Illustrations of these underlying principles and experimental support for the use of combined treatments are drawn from smoking cessation research, which has broadly applied combined behavioral and pharmacological therapies for treating abuse of nicotine, a mild stimulant. In addition, the results of recent studies that have evaluated the efficacy of behavioral techniques and/or potential pharmacotherapies for treating cocaine abuse are reviewed. Finally, methodological strategies are recommended for future evaluations of combined therapy approaches to conclusively evaluate separate and combined efficacy of treatments for psychostimulant abuse.

Successful Treatment of Severe Self Injury Incorporating the Use of DRO, a Snoezelen Room and Orientation Cues

Strong experimental evidence exists for the use of differential reinforcement procedures in ameliorating SIB in people with learning disabilities. However, recently some researchers have pointed out the inadequacy of single element treatment approaches in dealing with all cases of SIB and have stressed the need for services to develop multi‐modal, integrative intervention programmes based on non‐aversive approaches. This case report describes a treatment package for severe self‐injurious behaviour containing elements of DRO, use of a Snoezelen Room, orientation cues and staff support. Results showed the treatment programme to have been highly successful, with a marked reduction in the subject's SIB, along with a general increase in positive behaviours. A six‐month follow‐up study demonstrated that this improvement had been maintained. Thus, it was concluded that this study offers support for the concept of a multi‐faceted treatment package and rather more tentatively for the use of a Snoezelen Room as a component of such a package for some individuals.