Unfortunately, not all treatment options available for adults with anxiety disorders are available for children and adolescents. Benzodiazepines, common in adult populations, carry a high risk of sedation, dependence, and withdrawal, making them inappropriate choices for first-line therapy in children. The few studies evaluating tricyclic antidepressants in children have yielded conflicting results, and these also carry a risk of unwanted side effects. Several studies report the effectiveness of certain selective serotonin reuptake inhibitors (SSRIs), but still more promote the benefits of cognitive behavioral therapy (CBT). Few studies, however, compare the two, or evaluate the effectiveness of combined therapy.

A new study in the New England Journal of Medicine reports that a combination of CBT and the SSRI sertraline (Zoloft) is more effective than either therapy alone. The researchers assessed nearly 500 children between the ages of 7 and 17 years who had a diagnosis of separation anxiety disorder, generalized anxiety disorder, or social phobia. More than three-quarters of the patients had diagnoses of 2 or more anxiety disorders. The study population was evenly divided between boys and girls, and most of the children were white and middle-class. The severity of anxiety was examined over 12 weeks using the Clinical Global Impression-Improvement scale and the Pediatric Anxiety Rating Scale, and the children were randomized to receive either 14 sessions of CBT, a daily dose of sertraline, a combination of CBT and sertraline, or a placebo pill.

More than 80% of the children who received combination therapy reported that their anxiety was improved at the end of the study. This was significantly better than either therapy alone. CBT alone produced nearly 60% improvement rates, and sertraline alone produced nearly 55% improvement. All therapies were superior to placebo. Adverse events were reported with the same frequency in the sertraline and the placebo group. As expected, there was less insomnia, fatigue, sedation, and restlessness associated with CBT than sertraline. Sertraline, along with the other SSRIs bears a black-box warning regarding the increased risk of suicide in adolescents, but this risk has not been present in this or many other studies evaluating the safety of sertraline.

There are many considerations in choosing the right therapy for anxiety disorders, especially for pediatric patients. The family’s treatment preferences, as well as availability, cost, and time commitments, need to be weighed by the patient, family, and health care provider. All 3 options — drug therapy, CBT, or a combination of both — are safe and effective interventions for children with anxiety disorders. No matter what treatment option is chosen, however, early identification and intervention are critical to improve immediate and long-term outcomes for children with anxiety disorders.

References

(2004). Cognitive-Behavior Therapy, Sertraline, and Their Combination for Children and Adolescents With Obsessive-Compulsive Disorder: The Pediatric OCD Treatment Study (POTS) Randomized Controlled Trial JAMA: The Journal of the American Medical Association, 292 (16), 1969-1976 DOI: 10.1001/jama.292.16.1969

Juliette Liber, Brigit van Widenfelt, Arnold Goedhart, Elisabeth Utens, Adelinde van der Leeden, Monica Markus, Philip Treffers (2008). Parenting and Parental Anxiety and Depression as Predictors of Treatment Outcome for Childhood Anxiety Disorders: Has the Role of Fathers Been Underestimated? Journal of Clinical Child & Adolescent Psychology, 37 (4), 747-758 DOI: 10.1080/15374410802359692

M. A. Rynn (2001). Placebo-Controlled Trial of Sertraline in the Treatment of Children With Generalized Anxiety Disorder American Journal of Psychiatry, 158 (12), 2008-2014 DOI: 10.1176/appi.ajp.158.12.2008

Van Roy B, Kristensen H, Groholt B, Clench-Aas J. Prevalence and characteristics of significant social anxiety in children aged 8-13 years : A Norwegian cross-sectional population study. Soc Psychiatry Psychiatr Epidemiol. Nov 8 2008.

J. T. Walkup, A. M. Albano, J. Piacentini, B. Birmaher, S. N. Compton, J. T. Sherrill, G. S. Ginsburg, M. A. Rynn, J. McCracken, B. Waslick, S. Iyengar, J. S. March, P. C. Kendall (2008). Cognitive Behavioral Therapy, Sertraline, or a Combination in Childhood Anxiety New England Journal of Medicine, 359 (26), 2753-2766 DOI: 10.1056/NEJMoa0804633

I have to admit that this was not entirely shocking news to me, but I was slightly surprised to find the topic highlighted by NIMH as a “Science Update.” Granted, I don’t regularly read any psychiatric journals. I am a counselor by training, and typically receive only the professional publications that come with my professional association memberships. I suppose that I had just assumed that this was a well-researched topic. Obviously, the publications that I read are written from a different perspective. If the subject is featured, it is most likely written with the idea that therapy is inherently beneficial.

I teach in a counselor training program, and I would estimate that the majority of interventions that we discuss are primarily cognitive-behavioral in nature. Our counselors-in-training receive education is many different theoretical models, but cognitive-behavioral theory is the primary focus with respect to development of specific counseling skills.

So what is the “discovery” here? The connection with the treatment of adolescents?

The majority of my time spent in the field has been spent counseling adolescents. I’ve worked in conjunction with multiple psychiatrists over the years, and for the most part we have usually followed a similar protocol. All adolescents in treatment received counseling services. If warranted, the adolescent was seen by the psychiatrist for a medication evaluation (and management follow-up, if any medications were prescribed). One psychiatrist who I worked with, in particular, would cancel an appointment with the adolescent/family if they failed to keep their appointments with me (as their therapist).

My assumption here is that most practitioners and clients have had similar experiences. Therapy plus medication is more successful than medication alone. If that is true, why is this considered breaking news?

References

Kennard BD, Emslie GJ, Mayes TL, Nightingale-Teresi J, Nakonezny PA, Hughes JL, Jones JM, Tao R, Stewart SM, Jarrett RB (2008). Cognitive-behavioral therapy to prevent relapse in pediatric responders to pharmacotherapy for major depressive disorder J Am Acad Child Adolesc Psychiatry, 47 (12), 1395-1404 PMID: 18978634

The researchers conducted a year-long double-blind, placebo-controlled study of more than 800 postmenopausal women with low sexual desire who were not receiving estrogen therapy. The women were randomly assigned to receive a placebo, or a transdermal testosterone patch delivering either 150 micrograms (mcg) or 300 mcg of testosterone per day. The efficacy of the testosterone on libido was evaluated for 24 weeks, while the safety of the testosterone was evaluated for 52 weeks. A small subgroup of women was followed for an additional year to further evaluate the safety of daily testosterone therapy.

The women receiving 300 mcg of testosterone daily received the greatest benefit. The number of satisfying sexual encounters increased significantly to 2.1 episodes per 4-week period, compared to 0.7 episodes in the placebo group. The women receiving 150 mcg of testosterone daily also experienced an increase in sexual encounters (1.2 episodes per 4-week period) compared to the placebo group, but the change was not statistically significant. Both doses of testosterone were associated with significant increases in sexual desire, as well as decreases in distress.

The long-term follow-up period of the study was sufficient to discover some significant adverse effects associated with testosterone treatment. Most significantly was the rate of unwanted hair growth in the women receiving testosterone, with 30% experiencing this effect in the higher-dose group, and 23.1% in the lower-dose group. Also, 4 cases of breast cancer were diagnosed among the study participants receiving testosterone, compared to no new cases in the placebo group. One of these new cases was diagnosed in the first 4 months of the study, and another case had symptoms of breast cancer before the study began.

Another recent study in The Annals of Internal Medicine also studied transdermal testosterone treatment alone for low libido, but evaluated premenopausal women. The 261 women involved in this study applied a testosterone spray to the abdomen daily, and also experienced a significant increase in sexual desire and satisfaction. However, this was a smaller, shorter study, and included women who had low testosterone levels at baseline.

Most studies of low libido in women report success with combination estrogen and testosterone therapy. This new research, however, provides and option for women who cannot or will not be treated with estrogen therapy. It may offer treatment options for younger groups of women experiencing low sexual desire, or offer options for special patient populations, including cancer survivors, or those who have lost ovarian or uterine structures of function due to disease or surgery. More long-term safety studies are needed to fully evaluate the risks associated with long-term testosterone treatment in women, but the results are promising for women with low sexual desire and function.

References

D. L. Barton, D. B. Wender, J. A. Sloan, R. J. Dalton, E. P. Balcueva, P. J. Atherton, A. M. Bernath, W. L. DeKrey, T. Larson, J. D. Bearden, P. C. Carpenter, C. L. Loprinzi (2007). Randomized Controlled Trial to Evaluate Transdermal Testosterone in Female Cancer Survivors With Decreased Libido; North Central Cancer Treatment Group Protocol N02C3 JNCI Journal of the National Cancer Institute, 99 (9), 672-679 DOI: 10.1093/jnci/djk149

S. R. Davis, M. Moreau, R. Kroll, C. Bouchard, N. Panay, M. Gass, G. D. Braunstein, A. L. Hirschberg, C. Rodenberg, S. Pack, H. Koch, A. Moufarege, J. Studd (2008). Testosterone for Low Libido in Postmenopausal Women Not Taking Estrogen New England Journal of Medicine, 359 (19), 2005-2017 DOI: 10.1056/NEJMoa0707302

Davis S, Papalia MA, Norman RJ, et al. Safety and efficacy of a testosterone metered-dose transdermal spray for treating decreased sexual satisfaction in premenopausal women: a randomized trial. Ann Intern Med. Apr 15 2008;148(8):569-577.

Trichotillomania is seen to have a neurobiological basis. Because it is triggered by a variety of stressful or traumatic life events, simple one-fit-all treatment modalities such as use of anti-depressant medications (e.g. SSRIs) will not completely cure the trichotillomania. There is no magic pill or quick fix for trichotillomania management. It is a complex disorder and requires equally complex therapy.

A recent study published in Behaviour Research and Therapy examined possible phenomenological differences between the automatic and focused styles of pulling in youths with trichotillomania. It looked at differences in severity, phenomenology, co-morbid psychiatric symptoms, and functional impact in individuals with varying levels of hair pulling styles. Youths between the ages of 10 and 17 years were asked to participate in the study via an Internet-based survey. 186 individuals with chronic hair pulling behavior were classified as “high-focused” or “low-focused” and either “high-automatic” or “low-automatic” when pulling out their hair. These classifications were based upon scores obtained on the Milwaukee Inventory for Styles of Trichotillomania-Child Version (MIST-C).

Results demonstrated large differences in pulling styles. “High-focused” pullers reported more severe trichotillomania and greater symptoms of anxiety and depression than “low-focused” pullers, and “high-automatic” pullers reported greater symptoms of depression than “low-automatic” pullers.

This study is the first of its kind to highlight the different trichotillomania presentations and the wide range of symptom severity. Health professionals need to be aware of the constellation of possible symptoms, and treat trichotillomania on a case-by-case basis, using a extensive assortment of treatment options.

Reference

C FLESSNER (2008). Styles of pulling in youths with trichotillomania: Exploring differences in symptom severity, phenomenology, and comorbid psychiatric symptoms? Behaviour Research and Therapy, 46 (9), 1055-1061 DOI: 10.1016/j.brat.2008.06.006

Fast forward to the 21st century, electricity is now being explored for its potential to improve neurological function. A recent study at Beth Israel Deaconess Hospital and Harvard Medical School suggests that electrical stimulation of the brain may improve dexterity. In this study, 16 right-handed volunteers were fitted with scalp electrodes and weak noninvasive direct currents were transmitted through their skulls to neurons in the motor cortex. Prior to, and after each stimulation, the participants were asked to perform finger-sequencing tasks on a standard keyboard with the non-dominant hand.

The results were amazing. With electrical stimulation of the motor cortex, significant improvements in motor function in the non-dominant hand were seen. Dual stimulation of the right and left motor cortex regions, resulted in improvement of scores by almost 25%. Stimulating only one motor region showed a smaller increase (16%).

The mechanism of action, like ECT, is not is not clear. However, it is believed that transcranial direct current stimulation (tDCS) increases neuron excitability and may provide an environment supportive for motor skills recovery. Although the physiology is unknown, the implications and possible applications of this procedure is profound. Stroke victims, and people suffering from other conditions where motor function is lost or reduced may be able to acquire new skills or recover some lost motor function.

Reference

Bradley W Vines, Carlo Cerruti, Gottfried Schlaug (2008). Dual-hemisphere tDCS facilitates greater improvements for healthy subjects’ non-dominant hand compared to uni-hemisphere stimulation. BMC Neuroscience, 9 (1) DOI: 10.1186/1471-2202-9-103

The study participants were aged 16 years or older, and experienced between 10 and 17 seizures per month. Patients continued to take 1 to 3 previously prescribed antiepileptic drugs (AEDs) while taking lacosamide in the study. Nearly half of the study participants had tried 7 or more AEDs, and still experienced a lack of seizure control.

Patients taking lacosamide had seizures reduced by half overall, as well as a significant reduction in seizure frequency. More than 3% of patients taking lacosamide achieved complete seizure freedom during the study period, compared with less than 1% of those taking placebo.

Lacosamide is a new chemical entity that works by modulating sodium channels in the nervous system, as well as binding to a mediator protein that affects the growth and differentiation of nerve cells. It is not precisely understood how these two entities work together to control seizures. Lacosamide is given twice daily, has a low potential for drug interactions, and is well tolerated by study participants. The most commonly reported adverse events were dizziness, headache, and nausea.

The starting dose of lacosamide is 50 mg twice daily, and can be increased to 200 to 400 mg daily, divided into 2 doses. It is available as oral tablets and as an intravenous solution for short-term inpatient replacement therapy. No dose adjustment is required when switching from the oral to the intravenous forms. The intravenous infusion has also been well tolerated by patients, with injection site pain being noted as an adverse reaction. In no case was an adverse reaction to lacosamide the cause for discontinuation of the drug or the study. An oral solution is under development by the manufacturer.

As with other AEDs, lacosamide can increase suicidal thoughts and behaviors. All patients receiving an AED should be monitored for significant changes in mood or behavior. Caution with lacosamide is also advised for patients with severe cardiac disease or those taking drugs that can affect cardiac conduction.

Like many AEDs, lacosamide will be designated a controlled substance, but this classification is under review. The drug is expected to be available in the United States in early 2009, and marketed under the trade name Vimpat. The Belgian drug maker UCB manufactures Vimpat. They are also seeking approval for lacosamide as monotherapy in diabetic neuropathy, but the FDA issued a nonapproval letter for this indication, requesting that more studies are needed. Lacosamide was approved for use in patients with partial seizures not experiencing generalization by the European Medicines Agency in the European Union in September 2008.

Epilepsy affects nearly 50 million people worldwide, with 3 million in the United States. Less than half of these patients achieve seizure control with their first AED. Lacosamide is a significant step forward in improving the quality of life of many people suffering from epilepsy, its debilitating effects, and the adverse reactions to many AEDs currently on the market.

References

Victor Biton, William E. Rosenfeld, John Whitesides, Nathan B. Fountain, Nerija Vaiciene, G. David Rudd (2008). Intravenous lacosamide as replacement for oral lacosamide in patients with partial-onset seizures Epilepsia, 49 (3), 418-424 DOI: 10.1111/j.1528-1167.2007.01317.x

P DOTY (2007). Lacosamide Neurotherapeutics, 4 (1), 145-148 DOI: 10.1016/j.nurt.2006.10.002

Both physical and psychological factors are believed to be involved in the development of chronic pain, and individual differences exist in pain sensitivity and tolerance, making treatment difficult. Current treatment options for chronic pain include analgesic drugs, physical activity and rehabilitation, antidepressant medications, and behavior modification, but patients rarely experience a decrease in symptoms over time. Since the condition is believed to have biological and psychological causes, new treatment options are focusing on treatment options that enhance mind-body awareness and control. A study published in BMC Musculoskeletal Disorders in September reports positive effects of hypnosis for the treatment of chronic widespread pain.

Hypnosis is not routinely used in general treatment programs in the United States, but is garnering more attention is recent years, as scientists search for effective, holistic treatment options for chronic pain. Many small studies have shown that hypnosis can provide at least temporary pain relief, and may also lead to a reduction in pain over time. Such approaches to pain management can enhance quality of life and reduce disability related to chronic pain.

The current study involved 16 men and women, aged 23 to 54 years, who were randomized to a treatment group or a non-treatment control group. The treatment group participated in 30-minute hypnosis treatment sessions once weekly for 10 weeks. Both groups continued to receive standard treatments, including analgesic and antidepressant drugs, physiotherapy, and chiropractic therapy. After the initial 10-week treatment period, the patients in the control group were offered hypnosis therapy. Patients completed a 25-item questionnaire evaluating pain, fatigue, concentration problems, activities of daily living, pain interference in work and social life, anxiety and pessimism, and overall quality of life. These subjective scores were rated on a scale from 1 to 100, with higher numbers representing more suffering.

In total, 7 patients from the initial treatment group, plus 5 from the original control group, completed hypnosis therapy. These 12 patients experienced a significant reduction in pain and suffering scores, with a mean improvement of 9.9 points, from 51.5 to 41.6. The 7 patients from the initial treatment group experienced a significant score reduction from 62.5 to 55.4. The 5 patients who completed hypnosis treatment after participating in the control group experienced a near 13-point improvement in functioning, with scores decreasing from 35.97 to 23.54. The 8 patients in the initial control group showed an increase in suffering, with a near 8-point score increase from 37.2 to 45.1.

All 12 patients that completed hypnosis therapy completed follow-up after 1 year, and reported a score of 41.3, indicating maintenance of quality of life improvement. All of the patients reported using self-hypnosis methods at least once weekly during the year and would have taken advantage of additional hypnosis therapy if it had been available.

The small sample size and subjective nature of the questionnaire limits widespread application of these results. Also, the large difference in the baseline scores of the treatment and control groups may indicate unreliability in comparing the 2 groups.

However, many small studies have shown similar results, and a plausible approach to treating chronic pain is to combine pharmacological, physical, and psychological modalities based on each patient’s needs.

References

Carli G, Suman AL, Biasi G, Marcolongo R, Santarcangelo EL (2008). Paradoxical experience of hypnotic analgesia in low hypnotizable fibromyalgic patients. Arch Ital Biol, 146 (2), 75-82 PMID: 18822796

Jan Grøndahl, Elin Rosvold (2008). Hypnosis as a treatment of chronic widespread pain in general practice: A randomized controlled pilot trial BMC Musculoskeletal Disorders, 9 (1) DOI: 10.1186/1471-2474-9-124

M JENSEN, S HAKIMIAN, L SHERLIN, F FREGNI (2008). New Insights Into Neuromodulatory Approaches for the Treatment of Pain. The Journal of Pain, 9 (3), 193-199 DOI: 10.1016/j.jpain.2007.11.003

Molton IR, Graham C, Stoelb BL, Jensen MP (2007). Current psychological approaches to the management of chronic pain. Curr Opin Anaesthesiol, 20 (5), 485-489 PMID: 16911061

T OSBORNE (2006). Psychologic Interventions for Chronic Pain. Physical Medicine and Rehabilitation Clinics of North America, 17 (2), 415-433 DOI: 10.1016/j.pmr.2005.12.002

As Election Day draws near, I imagine that both McCain and Obama are exhausted; both have been run through the ringer. After all, they must endure non-stop campaigning schedules, high pressure debates, and the constant scrutiny of the press. Along with this, every aspect of their lives are being examined under the most powerful of microscopes. From tax records to religious affiliations to personal friendships, both men are left bare, no secrets uncovered.

This openness extends to their health histories as well. Both candidates issued records or statements detailing major health issues. Not surprisingly, Obama, 25 years younger than McCain, has a clean bill of health; the only exception is his difficulty kicking the smoking habit.

McCain’s record is fairly impressive as well even though he is 72. Along with his past problems with melanoma he may need joint replacement therapy down the road, a result of his time spent as a Prisoner of War (POW). Along with this, his records note that he tried to hang himself, eight months into his 5+ years spent as a POW. He was found to be mentally stable after being examined for mental disorders and we can assume that his suicide attempt was a rational decision considering the circumstances he was in.

Initially I was surprised upon reading this. After all, McCain’s strength of character, proven by his perseverance during his POW days as well as through other reports from those who know him well, seems to be contrary to this act of desperation. Don’t get me wrong, I don’t fault McCain because of this; he is a human susceptible to human weaknesses and certainly he was in the midst of more devastation and pain than many of us can imagine. This image just didn’t concur with the fiery candidate that I see on TV.

But eventually my surprise over his health details gave way to curiosity. Today he still suffers from ailments related to his time spent representing our country. This coincides with the reports that McCain’s patriotism and dedication to his country is intense. And it seems as if this would go a long way towards drawing voters. After all, for a future president, what speaks louder than loving your country so much that you are willing to suffer intensely?

Well, quite a bit it seems.

Most polls show McCain trailing Obama by a substantial margin. It seems that there is something more important to people than patriotism, the good old-fashioned War World II Generation-goodness. Don’t get me wrong, I do not doubt Obama’s patriotism but McCain’s past is textbook-flag-waving-country-first-stuff.

What is it that Americans value more highly than what McCain offers? Obama’s calmer and steadier demeanor? Liberal views? A change in ranks? Do our changing values represent progress? I don’t know.

But what I do know is that McCain’s type of patriotism may be dying. Excluding the military, you seldom hear young people talk about their country in endearing terms. And you certainly don’t see many who feel so strongly for their country that they are willing to put country above all else.

Obama may be the face of the future but for the sake of our country, I hope that McCain’s brand of patriotism isn’t a thing of the past.

Reference

F. Charatan (2008). Records of presidential candidates show McCain has had melanoma and Obama is using nicotine replacement therapy BMJ, 337 (oct27 2) DOI: 10.1136/bmj.a2260

In mirror therapy, a mirror is placed beside the unaffected limb, blocking the view of the affected limb. This creates the illusion that both limbs are functioning properly. Mirror theory is based on evidence that action observation activates the same motor areas of the brain as action execution. Observed actions lead to the generation of intended actions, engaging motor planning and execution. Further, evidence suggests that damaged areas of the brain’s motor cortex may improve by viewing movements of intact, functioning limbs.

Strokes can cause much neurological impairment, which may lead to a reduction in the performance of activities of daily living. Current rehabilitation techniques focus on occupational and physical therapy, using guided limb manipulation and task-oriented training. These exercises combine passive and active movement in an attempt to rebuild neuronal connections damaged by the stroke. Adding mirror therapy to traditional therapy enlists visual stimulation showing proper functioning. This points to a large cognitive role in rehabilitation, rather than just physical.

In the current study, 14 stroke patients with lower-limb hemiplegia were randomized to begin traditional rehabilitation therapies with or without the addition of mirror therapy. The study was a crossover design, and patients crossed to the other treatment arm after an initial treatment period. The subjects sat in a chair with a mirrored box placed over their lower limbs. They stepped over a 3-cm high step 10 times, and the angle of the ankle joint, as well as the time required to complete the task, were calculated.

Among this group of patients, the time required to complete the task was significantly shorter in the mirror therapy group, 2.80 seconds compared with 3.19 seconds in the non-mirror group. This translates to an approximate 12% acceleration of movement in the mirror therapy group. There was no significant difference in ankle flexion between the groups.

This is not the first study to report the positive effects of added mirror therapy in stroke patients. A randomized, controlled 4-week trial of 40 stroke patients concluded that hand functioning improved more after the addition of mirror therapy compared to conventional stroke rehabilitation programs. This study measured motor functioning and spasticity using standard instruments for recording physical rehabilitation, including the Modified Ashworth Scale (MAS) and the Functional Independence Measure (FIM). Additionally, a similar study of another 40 stroke patients found mirror therapy enhanced lower-extremity motor recovery. This study measured motor functioning and spasticity using the MAS, the FIM, and measured walking ability. The study presented at the World Stroke Congress is among the first to report speed of movement as a result.

Interestingly, the principles of mirror therapy have been applied to other techniques for stroke rehabilitation and used to develop virtual-reality based therapy systems for physical therapy programs. A recent study reported positive preliminary results from such a method that combines action observation with goal-directed movement imagery.

Hemiplegia is one of the most common consequences of strokes and presents great challenges for rehabilitation. With more evidence focused on visual and cognitive techniques to enhance traditional therapies, the mental and intellectual processes involved in rehabilitation are recognized as important factors in physical recovery. Now, a simple optical illusion could reflect great strides in stroke recovery.

References

Kynan Eng, Ewa Siekierka, Pawel Pyk, Edith Chevrier, Yves Hauser, Monica Cameirao, Lisa Holper, Karin Hägni, Lukas Zimmerli, Armin Duff, Corina Schuster, Claudio Bassetti, Paul Verschure, Daniel Kiper (2007). Interactive visuo-motor therapy system for stroke rehabilitation Medical & Biological Engineering & Computing, 45 (9), 901-907 DOI: 10.1007/s11517-007-0239-1

D ERTELT, S SMALL, A SOLODKIN, C DETTMERS, A MCNAMARA, F BINKOFSKI, G BUCCINO (2007). Action observation has a positive impact on rehabilitation of motor deficits after stroke NeuroImage, 36 DOI: 10.1016/j.neuroimage.2007.03.043

S SUTBEYAZ, G YAVUZER, N SEZER, B KOSEOGLU (2007). Mirror Therapy Enhances Lower-Extremity Motor Recovery and Motor Functioning After Stroke: A Randomized Controlled Trial Archives of Physical Medicine and Rehabilitation, 88 (5), 555-559 DOI: 10.1016/j.apmr.2007.02.034

G YAVUZER, R SELLES, N SEZER, S SUTBEYAZ, J BUSSMANN, F KOSEOGLU, M ATAY, H STAM (2008). Mirror Therapy Improves Hand Function in Subacute Stroke: A Randomized Controlled Trial Archives of Physical Medicine and Rehabilitation, 89 (3), 393-398 DOI: 10.1016/j.apmr.2007.08.162

Who would have thought that oranges and lemons, fruits easily found in a local grocery store, may hold the answer to curing cancer? Oranges vs. cancer — it does not seem like a contest. Cancer has been winning for decades almost unmitigated. Dedicated researchers for years have diligently pursued a cure for cancer. Sometimes the paths they take are not original, but are extensions of concepts previously unexplored or not fully developed. Such is the case with treatment of cancer with vitamin C, or ascorbic acid, an essential nutrient contained in citrus fruits like oranges and lemons.

Vitamin C was previously explored as a treatment for cancer. The hydrogen peroxide generated by high concentrations of vitamin C (above 1,000 µmol/L) were found to be selectively cytotoxic to cancer cells in vitro. Normal cells were not harmed. Nobel Prize laureate in chemistry, Linus Pauling, advanced this idea in the 1970s with trials involving large doses of orally ingested ascorbic acid. The trials, unfortunately, did not show conclusive benefits and the controversial method for cancer treatment was largely ignored by most oncologists. It did, however, remain a popular alternative cancer treatment for many health practitioners.

What’s old may be becoming new again. Treating cancer with ascorbic acid is generating new buzz. This time, however, treatment will be in the form of injections of vitamin C. It turns out that no matter how many oranges, lemons, or vitamin C tablets are ingested, it does not enter the system in sufficient amounts to effect cancer cells. Only injected doses of vitamin C raise the blood level concentration to levels necessary to disrupt and harm cancer cells in laboratory experiments.

Even now, it is not universally accepted that injected vitamin C will be the successful cancer therapy that has been eluding scientists for generations. Some case reports have advanced the use of parenteral vitamin C as an agent against cancer. In three such reports, terminally ill cancer patients with pulmonary metastatic renal cancer, bladder tumor, and diffuse large B-cell lymphoma were injected with vitamin C. The patients improved significantly and had a prolonged life span. These results have not, however, passed the guidelines of the US National Cancer Institute because of insufficient data and inadequate follow-up. In addition, the cases did not have objective pathologic confirmation. So, although promising, injected vitamin C will require larger studies and conclusive benefits before expanding beyond an alternative therapy for cancer.

References

Q. Chen, M. G. Espey, A. Y. Sun, C. Pooput, K. L. Kirk, M. C. Krishna, D. B. Khosh, J. Drisko, M. Levine (2008). From the Cover: Pharmacologic doses of ascorbate act as a prooxidant and decrease growth of aggressive tumor xenografts in mice Proceedings of the National Academy of Sciences, 105 (32), 11105-11109 DOI: 10.1073/pnas.0804226105

S. J. Padayatty (2006). Intravenously administered vitamin C as cancer therapy: three cases Canadian Medical Association Journal, 174 (7), 937-942 DOI: 10.1503/cmaj.050346

CST is based on the principle that the cranial bones, the vertebrae and sacrum share an intrinsic rhythm with the ligaments, muscles and fascia that surrounds them. This rhythm, when synchronized, facilitates smooth movement and circulation of the cerebrospinal fluid. This in turn maintains good lubrication within the intervertebral and facet joints of the spine, and contributes to good health and functionality of the spine and other body systems. This rhythm is termed as the “Breath of Life” and is similar to the concept of “Prana” in Eastern medicine. What craniosacral therapists aim to do is “read” or tap into this rhythm and move their hands in sync with the body to normalize the system. Certain key points on the body –- such as the base of the skull, the area over the sacrum and diaphragm are given special importance to release the soft tissue or bony blocks, so that movement and flow are optimized.

As a physical therapist, I am able to relate to the importance of touch and hand placement to elicit optimal neuromuscular response. The theory of embryonic maturation also supports the principles of CST. During embryogenesis, the same dermal layer (ectoderm) that differentiates to form the skin also develops into the brain and nerves. So in a manner of speaking when we place our hands on any part of a person’s body, we are indirectly communicating with the nervous system. I would love to explore this avenue of treatment further and add it to my “toolbox” of techniques. Currently one can attend hands-on workshops and short-term courses to learn this technique; there are no degrees or certifications possible in CST. CST also gets its share of flak from skeptics. They question the very existence of a craniosacral rhythm and its link to health, and argue that there is lack of evidence to confirm efficacy of the approach. The hugely subjective nature of the entire process, with limited or no objective measurement also takes away points from the technique.

Detractors argue that CST is unscientific, and that it just poses a feel good effect. But so what if patients feel better based merely on the relaxing atmosphere and their faith in the healing process of CST? Isn’t that the ultimate goal of all healers? To send the patient home relaxed and in less pain? In an ideal world, a relatively low-risk technique that is non-invasive and offers relief from symptoms (subjective reports from patients) would be encouraged, even lauded. However, in a world where healthcare costs are constantly being contained, and where third party payers dictate number of visits for treatments; a process that lacks hard, in-your-face evidence will surely be frowned upon. It is important not to completely disregard techniques such as CST based solely on the lack of evidence. Opening our minds to other treatment forms and alternative medicine can only obliterate the boundaries that we set for ourselves and help us expand — professionally and personally.

In the USA, there has been growing emphasis on documentation and maintaining good health records in the field of healthcare over the past few years. As a rehabilitation professional, I used to find summarizing the activities of a one-hour session into a paragraph of words somewhat challenging. But over the years, one tends to accept medical notes as part of one’s work, gradually getting more efficient at it. Documentation is primarily viewed as a means to communicate episodes of care to third party payers for reimbursement purposes. However, detailed documentation and well-organized records also serve to benefit the healthcare professional and the consumer. Some of the benefits of good quality documentation are:

• Maintaining records so that administrative operations may be evaluated based on the recommendations of accrediting and certifying organizations.
• Maintaining privacy and security of personal healthcare records.
• Maintaining records to keep up with the expectations of the educated consumer.
• Legal record of all communication between professional and consumer in case of disputes.

In the field of therapy and rehabilitation, the typical evaluation form has a section for goal setting. Personally, I think this is invaluable, as it gives the professional a chance to ask patients and their families what their expectations from therapy are, thereby including them in the process from the beginning. This is the foundation of the Interdisciplinary model of healthcare delivery, which places the patient and family at the center of the planning process. When goals are set early on, the rehabilitation plan is better outlined and specific to the patients’ needs. Studies have indicated that efficient goal planning and documentation improve patient compliance and participation in the program. Studies also suggest that concise and systematic goal planning has a positive effect on patient outcome.

To increase efficiency and ease of storage, hospitals and clinics are moving form the traditional pen and paper documentation toward electronic medical records (EMR). The technology boom has certainly affected healthcare; now documentation may be done on word processing software, over the Internet, or telephonically via dictation systems.

“Working from home” — a concept alien in rehabilitation — is now becoming a possibility; the EMR gives therapists the choice of completing notes at home.

Studies suggested that EMR improved reporting capabilities, and provided a standardized system to analyze and measure therapy outcomes. Studies also showed that EMR enabled individualized treatment planning for clients. Other benefits of EMR included improved efficiency of patient admission processes, decreased length of rehabilitation stay, improved communication within the team, and reduced duplication of information. Another advantage of the EMR is maintaining continuum of care, as the records are available to the entire treatment team for reference and for planning treatment sessions.

Maintaining current and accurate medical records is the responsibility of every healthcare professional. There are more advantages than disadvantages to this and timeliness of documentation benefits the consumer, the providers and companies that bear healthcare costs.

The problem with this approach is that there is really no such thing as sham acupuncture.

In the mechanistic, Western view of the body and medicine, acupuncture is the sum of the parts, so it works like this:

problem + needle + point on meridian = problem gets better

You can insert other things in place of “needle + point on meridian” and you’ll still have an accurate model for Western medicine.

problem + medication = problem gets better
problem + surgery = problem gets better

Each of these focuses on a specific functional or anatomic mechanism for ill health. High blood pressure? Take a beta blocker. Blocked coronary arteries? Replace them with femoral veins (better yet, internal mammary arteries).

In this view, placebos make perfect sense as a way of proving that interventions work:

problem + thing that looks like medication but isn’t = problem doesn’t get better

Here’s where the mechanistic view of the body and how medicine works fails to meet the holistic view. Acupuncture can’t be shoved into the mechanistic “if A, then B” box of randomized, controlled trials.

Solid evidence is emerging that the effects of acupuncture are mediated through the limbic-paralimbic-neocortical network. It plays a central role in the affective and cognitive dimensions of pain–and in regulating and integrating emotion, memory processing, autonomic, endocrine, immunological, and sensorimotor functions.

For instance, a recent study using functional MRI of the brain to trace the effects of acupuncture in the brain stimulated four points: Taichong (LV3), Xingjian (LV2), Neiting (ST44), and a sham point on the top of the left foot. The hemodynamic response was similar for all four points, as was the sensory experience as reported by the study subjects. Regardless of the point being needled, acupuncture produced extensive deactivation of the limbic-paralimbic-neocortical system.

In short, there is no such thing as sham acupuncture. Because the cognitive, affective, and physical intertwine in the limbic-paralimbic-neocortical network, there’s no way to have a needle stuck into you without experiencing at least some of the effects of acupuncture.

You might think that this would be good news for proponents of acupuncture. One way to interpret this information is that acupuncture is such a robust modality, it’s effective even when used outside traditional guidelines.

However this probably won’t come as a great surprise–from the Western perspective, interventions remain suspect if they can’t be isolated and controlled for. Even as acupuncture gains a toehold in Western medicine, it’s unlikely to ever be fully accepted as a treatment modality.

Reference

Fang, J., Jin, Z., Wang, Y., Li, K., Kong, J., Nixon, E.E., Zeng, Y., Ren, Y., Tong, H., Wang, Y., Wang, P., Hui, K.K. (2008). The salient characteristics of the central effects of acupuncture needling: Limbic-paralimbic-neocortical network modulation. Human Brain Mapping DOI: 10.1002/hbm.20583

Starting in May 2007, the FDA started requiring that a warning be posted on antidepressant drugs. The warning was about the increased risk of suicide for patients in the 18-24 age range. This warning was the result of a FDA analysis of patient data.

So it seems to me that depressed young people need more options besides medication. Of course, all people who suffer from depression need options but for this age group, in light of this study, it seems necessary. So, let’s look at other possible options.

Therapy: This is a standard treatment and it can be a good one. But unfortunately this method of treatment requires a good therapist and this isn’t always easy to find. Not because there’s a shortage of capable therapist out there but because it can get complicated. Sometimes the therapist doesn’t practice the type of therapy that is best for your condition. Maybe you live in a very small town with only 1 or 2 practicing therapists. Many times therapists don’t accept insurance or don’t accept your insurance.

In the case of depression, Cognitive Behavioral Therapy is one of the better therapy choices. But it can be hard to find a therapist that specializes in this type of therapy. Many may offer some form of it but there’s something to be said for someone who knows the intricacies of treating depression using only this therapy.

Classes: This isn’t a usual treatment option but I think it’s a good one. It’s my outside the box contribution, if you will. Many people who are depressed suffer from various thinking patterns that make depression more likely to occur or enable the depression to stay around. Bringing these patterns to patients’ attention and then teaching them other ways to think can go a long way towards helping a depressed individual become healthier.

Other Support Systems: There are a myriad of options available for supporting those with depression. Whether it is some type of group therapy, support group, or study group. One option that I find alluring is telephone treatment. This type of treatment was offered to over 604 employees aged 18 years and over in various U.S. companies. The treatment involved telephone assessment and facilitation to inpatient treatment, a psycho-educational workbook, support and monitoring of treatment. The results were very positive.

Although medication is usually the first or second line of defense against depression, there are more options available. Since medication may not the best treatment choice for many, and since traditional therapy isn’t always accessible, I think it’s necessary to search for other ways to offer support and help so that those who need to treat their depression have a number of viable, encouraging choices at their disposal.

References

Barbui, C., Cipriani, A., Geddes, J.R. (2008). Antidepressants and suicide symptoms: compelling new insights from the FDA’s analysis of individual patient level data. Evidence-Based Mental Health, 11(2), 34-35. DOI: 10.1136/ebmh.11.2.34

Gilbody, S. (2008). Telephone treatment support improves outcomes for depressed employees. Evidence-Based Mental Health, 11(2), 47-47. DOI: 10.1136/ebmh.11.2.47

Still, these drug experts are not granted prescriptive authority under state or federal laws. Of course, physicians, osteopaths, dentists, and veterinarians have long-standing authority and experience in writing medication orders and prescriptions. In most states, these practitioners are granted full prescribing rights to any medication available, whether or not it falls within the scope of his or her practice. Each state governs its own laws regarding the prescriptive authority of more specialized practitioners, including podiatrists, nurse practitioners, and physician assistants. In some states, these practitioners have broad prescribing powers, while other states limit the type or schedule of medication allowed to be prescribed, or require strict collaborative practice agreements with physicians. Yet, almost no state allows pharmacists to prescribe or manage medication therapy outside the strict bounds of tightly controlled protocols for relatively routine medications.

Nurse practitioners and physician assistants have fought long legal battles to change the regulations governing their practice and their prescriptive authority. As more legislation is poised to expand their role further in many states, these groups are exploring the opportunity for almost completely autonomous practice. These groups focus on education and training as part of their battle for professional independence, and do not take their prescriptive authority lightly. These practitioners emphasize the need for continued education as part of their expanding role, and it has paid off, as patients accept their role as prescribers freely and believe the practitioners are knowledgeable about medications.

Still, pharmacists are the profession with the most education and experience in drug therapy. Expanded prescriptive authority for pharmacists would have benefits in cost and safety for the public. Pharmacists already govern the dispensing of some medications in a quasi-prescriptive role. Such “behind the counter” medications require pharmacists to consult with patients prior to the sale of medications that do not require a prescription, but do necessitate some level of supervision by a health care provider. The pharmacist is required to assess a patient for medical history, current medications, and drug allergies before dispensing the medication. Many professional groups advocate for an expanded “pharmacist-only” class of over-the-counter medications to increase the public’s access to medications.

Several studies have shown positive outcomes when pharmacists are directly involved in the prescribing, dispensing, and managing patients’ medication therapies. Many test cases have allowed pharmacists to independently manage therapy for diabetes, and overall improvement in patient’s glycemic control was seen when pharmacists were afforded prescriptive authority. Further, a reduction in costs and use of health care resources was seen, since diabetes-related complications were diminished. Favorable outcomes were also achieved when pharmacists took a lead role in the prescription and management of medications to treat chronic pain patients. The patients were effectively treated and costs were reduced when pharmacists were allowed prescriptive authority.

Barriers do exist to pharmacists’ prescriptive authority. Among the most significant include workload and time demands, particularly in today’s busy community pharmacy settings. A busy pharmacy counter or drive-through does not provide a safe or appropriate arena for discussing medication management. Further, most insurance providers do not compensate pharmacists for providing any sort of medication management service and providing clinical care is expensive. However, the expanding clinical role of pharmacists in hospital, long term care, and outpatient settings increase the opportunity for medication therapy management programs in which pharmacists are integral providers of effective health care. Even in a community pharmacy, pharmacists are accessible to the public and they are poised to assess and counsel patients more easily than any other health care provider.

Pharmacists are well-trained and well-educated medical professionals with richly-developed clinical judgment and scientific skills that are unparalleled by any other medical profession. Pharmacists need to fulfill their potential as drug experts and increase the value and access of quality health care to the public. The profession of pharmacy — and the public — should challenge the notion that pharmacists merely count pills and demand that they be directly involved in the prescription and management of medication therapy.

References

Dole, E.J., Murawski, M.M., Adolphe, A.B., Aragon, F.D., Hochstadt, B. (2007). Provision of pain management by a pharmacist with prescribing authority. American Journal of Health-System Pharmacy, 64(1), 85-89. DOI: 10.2146/ajhp060056

Kaplan, L., Brown, M. (2004). Prescriptive Authority and Barriers to NP Practice. The Nurse Practitioner, 29(3), 28-35. DOI: 10.1097/00006205-200403000-00004

Kaplan, L., Brown, M. (2007). The Transition of Nurse Practitioners to Changes in Prescriptive Authority. Journal of Nursing Scholarship, 39(2), 184-190. DOI: 10.1111/j.1547-5069.2007.00165.x

McCann, T.V., Clark, E. (2008). Attitudes of patients towards mental health nurse prescribing of antipsychotic agents. International Journal of Nursing Practice, 14(2), 115-121. DOI: 10.1111/j.1440-172X.2008.00674.x

Wubben, D.P., Vivian, E.M. (2008). Effects of Pharmacist Outpatient Interventions on Adults with Diabetes Mellitus: A Systematic Review. Pharmacotherapy, 28(4), 421-436. DOI: 10.1592/phco.28.4.421