Betty Meyboom-de Jong

Risk factors for burn-out in caregivers of stroke patients, and possibilities for intervention:

Objective: To identify which caregivers of stroke patients living at home experience the highest levels of strain and are at risk of burn-out, and to investigate how support for caregivers of stroke patients could best be organized, and when this support should be offered. Design and setting: Caregivers of stroke patients were recruited in four regions of the Netherlands. A total of 212 caregivers were interviewed. Multiple stepwise regression analysis was performed to determine the effects of patient and caregiver characteristics, resources, coping strategies and duration of the caregiver role on caregiver strain, mental well-being and vitality. Subjects:The majority of the caregivers were female spouses. Their mean age was 64 years, and their socioeconomic status middle class. Stroke had occurred about 3.5 years ago on average. Main outcome measures:The following main outcome measures were used: the Caregiver Strain Index, and two scales of the Short Form-36 to measure caregivers’ mental well-being and vitality. Results: Severe cognitive, behavioural and emotional changes in the patient constitute the main risk factors for caregiver burn-out. Women, younger caregivers and caregivers in poor physical health were also identified as risk groups. Caregivers with high perceived self-efficacy, satisfied with social support, and frequently using the coping strategy confronting, experience less strain, higher mental well-being and greater vitality. Duration of the caregiver role does not influence caregivers’ strain, mental well-being or vitality. Conclusions: Women, younger caregivers, caregivers in poor physical health, and caregivers of patients with severe changes are at risk of burn-out. Support programmes should focus on self-efficacy, social support, and the coping strategy confronting. No specific moment could be identified at which support programmes should be offered.

Manipulative Therapy in Addition to Usual Medical Care for Patients with Shoulder Dysfunction and Pain: A Randomized, Controlled Trial

Context Shoulder pain in the absence of trauma, fracture, rupture, or dislocation can lead to substantial functional limitations and can be a difficult condition to treat. Contribution In this randomized, controlled trial, patients with shoulder pain and shoulder girdle dysfunction assigned to receive manipulative therapy in addition to usual general practitioner care had more rapid improvement in symptoms and fewer shoulder symptoms at 12 weeks than patients assigned to usual care alone. Implications Manipulative therapy appears to be an effective treatment option for patients with shoulder pain and shoulder girdle dysfunction that are not due to trauma, fracture, rupture, or dislocation. The Editors Shoulder disorders are a widely recognized medical, social, and economic problem (1). They are characterized by functional disability due to pain in the shoulder at rest or during movement or by functional disability due to restricted range of motion. The annual incidence of shoulder symptoms in Dutch general medical practices is estimated to be 10 to 25 per 1000 enrolled patients (2-4). In the Netherlands, shoulder disorders are treated according to the Guidelines for Shoulder Complaints of the Dutch College of General Practitioners (5, 6). Initial treatment during the first 2 weeks includes informing patients about the nature and course of shoulder symptoms and advising them on how to use the affected shoulder during daily living. Patients can also be prescribed analgesics or nonsteroidal anti-inflammatory drugs if necessary. If this initial treatment is not effective, up to 3 corticosteroid injections (in the subacromial space or glenohumeral joint) can be given. Referral for physiotherapy is considered only for patients whose symptoms persist for 6 weeks or more. This treatment regimen, according to the guidelines, provides short-term benefit for many patients but cannot prevent the often unfavorable long-term course of the symptoms. Indeed, only 50% of all new episodes of shoulder disorders resolve within 6 months, while at 12 months more than 40% of all patients are still disabled during work and leisure time (4, 7). Pain or dysfunction of the cervicothoracic spine and the adjacent ribs (also called the shoulder girdle) often accompanies shoulder symptoms (8). A considerable proportion of patients with shoulder symptoms (approximately 20%) but no shoulder joint disorders may be found to have dysfunction of the shoulder girdle on further physical examination (9). Moreover, dysfunction of the shoulder girdle triples the risk for shoulder complications (10) and also predicts poor outcome of shoulder disorders (10-12). In clinical practice, dysfunction of the shoulder girdle can be treated with manipulative therapy, which aims to restore normal function. Winters and colleagues (13) found that manipulative therapy accelerated recovery and improved symptoms compared with physiotherapy in a relatively small subgroup of patients with both shoulder symptoms and shoulder girdle dysfunction. These effects were not sustained on long-term follow-up, possibly because of high attrition rates (14). Evidence showing that manipulative therapy for the shoulder girdle effectively treats shoulder symptoms is scarce; Winters and colleagues have performed the only randomized trial (13, 14) to date. Our objective was to study the effectiveness of manipulative therapy for the shoulder girdle in addition to usual medical care by a general practitioner. The study design has been described elsewhere (15), and the trial was designed and reported accord ing to the Consolidated Standards of Reporting Trials (CONSORT) statement (16). We report the effects of the use of additional manipulative therapy for the shoulder girdle to treat shoulder symptoms. Methods Participants Potential eligible participants with shoulder symptoms (pain and dysfunction) were recruited in 50 general practices in Groningen, the Netherlands. General practitioners started initial treatment (usual medical care) at presentation, assessed eligibility criteria, and told the conducting researcher about each eligible patient. The general practitioner used a standardized eligibility checklist and a physical examination as recommended by the Dutch College of General Practitioners (5, 6). A baseline assessment at the research center was scheduled within 2 weeks of presentation. Shoulder symptoms were defined as pain between the neck and the elbow at rest or during movement of the upper arm (Figure 1). Pain radiating to the neck region or to the lower part of the arm was not used as an exclusion criterion. The physical examination established the presence of both shoulder symptoms and dysfunction of the cervicothoracic spine and the adjacent ribs with accompanying pain or restricted movement. Eligible patients were 18 years of age or older and had had no consultation or treatment for shoulder symptoms in the past 3 months. No limits were placed on duration of symptoms before the first consultation. Figure 1. Location of shoulder symptoms. Reasons for exclusion were acute severe trauma, such as fractures, ruptures, or dislocation in the shoulder region; previous orthopedic surgery; clear treatment preference deviating from the study protocol; contraindications to manipulative therapy (for example, hypermobility, instability, or severe arthrosis of the cervicothoracic spine); signs of cervical nerve root compression; presence of specific rheumatic disorders; presence of dementia or other severe psychiatric, emotional, or behavioral disorders; shoulder disorders due to general internal disease of thoracic and abdominal organs; and inability to complete Dutch-language written questionnaires. Eligibility and exclusion criteria were verified before randomization by using a structured medical history and physical assessment. Randomization Patients were evenly allocated to receive manipulative therapy plus usual medical care or usual medical care alone. An independent statistician not involved in recruitment of patients generated a random list that was stratified for general practitioner by permutation of randomized blocks, with a block size of 6. After eligibility was verified, written informed consent was obtained. A researcher opened preprepared numbered, opaque sealed envelopes containing the treatment allocation codes and made appointments with manual therapists when applicable. Interventions Usual Medical Care All patients received usual medical care from their general practitioners. Usual medical care was similar to that outlined by the Dutch College of General Practitioners (5, 6) and included information, advice, and therapy. During the first 2 weeks, patients were given information about the nature and course of shoulder symptoms, along with advice on daily use of the affected shoulder. Patients were prescribed oral analgesics or nonsteroidal anti-inflammatory drugs if necessary. The Dutch College of General Practitioners recommends 2 weeks of treatment with paracetamol, 4 times daily (maximum dosage, 4000 mg/d), or nonsteroidal anti-inflammatory drugs such as ibuprofen, 3 times daily (maximum dosage, 2400 mg/d); diclofenac, 3 times daily (maximum dosage, 150 mg/d); or naproxen, twice daily (maximum dosage, 1000 mg/d) (5, 6). If patients did improve, drug treatment could be extended for another 2 weeks. If this approach was ineffective, up to 3 corticosteroid injections could be given in either the subacromial space or the glenohumeral joint. For injections in either location, physicians used triamcinolone acetonide, 40 mg suspended in a 1-mL vehicle, if necessary, combined with lidocaine, 10 mg suspended in a 5- to 10-mL vehicle. If improvement remained insufficient 2 weeks after injections were given, injections could be repeated. Further corticosteroid treatment was not considered appropriate if patients did not improve after the second series of injections. For symptoms persisting at least 6 weeks, physiotherapy consisting of shoulder exercises, massage, and physical applications was considered. Other referrals during the intervention and follow-up periods (for example, to a rheumatology consultant or orthopedic surgeon) were discouraged but were documented if they occurred. Manipulative Therapy According to the International Federation of Orthopedic Manipulative Therapists, orthopedic manipulative (manual) therapy is a specialization within physical therapy and provides comprehensive conservative management for pain and other symptoms of neuro-musculo-articular dysfunction in the spine and extremities. Our approach to manipulative therapy focused on manual manipulation and mobilization techniques used in western Europe, North America, and Australia, including those described by Cyriax (17), Greenman (18), and Lewit (19). In our trial, manipulative therapy included specific manipulations (low-amplitude, high-velocity thrust techniques) and specific mobilizations (high-amplitude, low-velocity thrust techniques) to improve overall joint function and decrease any restrictions in movement at single or multiple segmental levels in the cervical spine and upper thoracic spine and adjacent ribs. The manual therapist chose the applied techniques on the basis of the location of the dysfunction and the therapists technique preferences. Within the boundaries of the protocol, treatment could be reassessed and adapted to the patients condition. A maximum of 6 treatment sessions could be given over a 12-week period. Eight experienced physiotherapists who were members of the Dutch Association of Manual Therapy and registered by the Royal Dutch Society for Physical Therapy (a member of the International Federation of Orthopedic Manipulative Therapists) provided the manual therapy. To minimize variations in manipulative therapy, therapists received a special training session to familiarize them with the protocols mobilization and manipulation techniques for treatment of the cervico

Long-term effects of amlodipine and lisinopril on left ventricular mass and diastolic function in elderly, previously untreated hypertensive patients : the ELVERA trial

Objective To compare the effects of a calcium antagonist (amlodipine) and an angiotensin converting enzyme inhibitor (lisinopril) on left ventricular mass and diastolic function in elderly, previously untreated hypertensives. Design A double-blind randomized parallel group trial. Effects of amlodipine and lisinopril on left ventricular mass and diastolic function (E/A Ratio) (The ELVERA trial). Setting Rural northern Netherlands: population screening new diagnosed hypertensive subjects. Patients The study population comprised 166 newly diagnosed hypertensive (aged 60–75) with diastolic blood pressure between 95–115 mmHg and/or systolic blood pressure between 160–220 mmHg. Intervention Patients were randomly allocated to receive 5–10 mg amlodipine or 10–20 mg lisinopril for 2 years. Main outcome measures Prior and after 1 and 2 years of treatment left ventricular mass, indexed by body surface (LVMI) was estimated by 2-D mode echocardiography according to Devereux with use of Penn convention. Early to atrial filling ratio (E/A) was assessed by transmitral flow. Change from baseline of LVMI and E/A ratio was evaluated by repeated measurement analysis of the treatment effect in an intention-to-treat analysis. Results Both amlodipine and lisinopril led to equivalent reduction in systolic and diastolic blood pressure. At the end of the study the amlodipine group led to LVMI decrease by 21.8 g/m ⩽ [95% confidence interval (CI), 18.3–25.3] and E/A ratio increased by 0.08 (95% CI, 0.05–0.11). In the lisinopril group LVMI decreased by 22.4 g/m ⩽ (95%, CI, 19.0–25.8) and E/A ratio increased by 0.07 (95% CI, 0.04–0.10). No statistically significant differences were found in changes in LVMI and E/A ratio between amlodipine and lisinopril. Conclusion A long-term study, the ELVERA trial proves that amlodipine and lisinopril reduce left ventricular mass and improve diastolic function to a similar extent in elderly newly diagnosed hypertensive patients.

Somatic diseases in patients with schizophrenia in general practice: their prevalence and health care

BackgroundSchizophrenia patients frequently develop somatic co-morbidity. Core tasks for GPs are the prevention and diagnosis of somatic diseases and the provision of care for patients with chronic diseases. Schizophrenia patients experience difficulties in recognizing and coping with their physical problems; however GPs have neither specific management policies nor guidelines for the diagnosis and treatment of somatic co-morbidity in schizophrenia patients. This paper systematically reviews the prevalence and treatment of somatic co-morbidity in schizophrenia patients in general practice.MethodsThe MEDLINE, EMBASE, PsycINFO data-bases and the Cochrane Library were searched and original research articles on somatic diseases of schizophrenia patients and their treatment in the primary care setting were selected.ResultsThe results of this search show that the incidence of a wide range of diseases, such as diabetes mellitus, the metabolic syndrome, coronary heart diseases, and COPD is significantly higher in schizophrenia patients than in the normal population. The health of schizophrenic patients is less than optimal in several areas, partly due to their inadequate help-seeking behaviour. Current GP management of such patients appears not to take this fact into account. However, when schizophrenic patients seek the GPs help, they value the care provided.ConclusionSchizophrenia patients are at risk of undetected somatic co-morbidity. They present physical complaints at a late, more serious stage. GPs should take this into account by adopting proactive behaviour. The development of a set of guidelines with a clear description of the GPs responsibilities would facilitate the desired changes in the management of somatic diseases in these patients.

Chromium Treatment Has No Effect in Patients With Type 2 Diabetes in a Western Population A randomized, double-blind, placebo-controlled trial

OBJECTIVE—Chromium treatment has been reported to improve glycemic control in patients with type 2 diabetes. However, concern exists about the possible toxic effects of chromium picolinate. The aim of this study was to determine the effect of chromium treatment in the form of chromium yeast on glycemic control in a Western population of patients with type 2 diabetes who were being treated with oral hypoglycemic agents. RESEARCH DESIGN AND METHODS—In this 6-month, double-blind study, patients with moderate glycemic control, being treated with oral hypoglycemic agents, were randomly assigned to receive either a placebo or treatment with 400 μg of chromium daily in the form of chromium yeast. The primary efficacy parameter was a change in A1C. Secondary end points were changes in lipid profile, BMI, blood pressure, body fat, and insulin resistance. RESULTS—No differences were found for the change in A1C between the intervention and placebo groups, nor were any differences found between the groups for the secondary end points. CONCLUSIONS—There is no evidence that chromium in the form of chromium yeast is effective in improving glycemic control in Western patients with type 2 diabetes who are taking oral hypoglycemic agents.

Can diabetes management be safely transferred to practice nurses in a primary care setting? A randomised controlled trial

AIMS AND OBJECTIVES To determine whether the management of type 2 diabetes mellitus in a primary care setting can be safely transferred to practice nurses. BACKGROUND Because of the increasing prevalence of type 2 diabetes mellitus and the burden of caring for individual patients, the demand type 2 diabetes mellitus patients place on primary health care resources has become overwhelming. DESIGN Randomised controlled trial. METHODS The patients in the intervention group were cared for by practice nurses who treated glucose levels, blood pressure and lipid profile according to a specified protocol. The control group received conventional care from a general practitioner. The primary outcome measure was the mean decrease seen in glycated haemoglobin (HbA1c) levels at the end of the follow-up period (14 months). RESULTS A total of 230 patients was randomised with 206 completing the study. The between-group differences with respect to reduction in HbA1c, blood pressure and lipid profile were not significant. Blood pressure decreased significantly in both groups; 7.4/3.2 mm Hg in the intervention group and 5.6/1.0 mm Hg in the control group. In both groups, more patients met the target values goals for lipid profile compared to baseline. In the intervention group, there was some deterioration in the health-related quality of life and an increase in diabetes-related symptoms. Patients being treated by a practice nurse were more satisfied with their treatment than those being treated by a general practitioner. CONCLUSION Practice nurses achieved results, which were comparable to those achieved by a general practitioner with respect to clinical parameters with better patient satisfaction. RELEVANCE TO CLINICAL PRACTICE This study shows that diabetes management in primary care can be safely transferred to practice nurses.

Corticosteroid injections effective for trigger finger in adults in general practice: a double-blinded randomised placebo controlled trial

OBJECTIVE To study efficacy and safety of corticosteroid injections for trigger finger (flexor tenosynovitis) in adults in general practice. METHODS Adult patients presenting with trigger finger were recruited by 21 participating general practitioners. In this randomised placebo controlled double-blinded trial, patients were injected locally with one or two injections of 1 ml triamcinolonacetonide (TCA) or 0.9% NaCl. Outcomes regarding immediate treatment response, severity of symptoms, functional disability, patient satisfaction and side effects were measured 1 week after intervention and during the 12 months thereafter. RESULTS A total of 50 patients were included. Short-term outcomes for the TCA and NaCl group, respectively, were: proportion of patients with satisfactory immediate treatment response 16/25 and 5/25 (p<0.001), patients with reduction in the frequency of triggering 13/24 and 6/22 (p = 0.053), mean difference in severity of pain 4.2 and 0.9 (p<0.001), patients perceiving improvement 22/25 and 9/25 (p<0.001) and difference in Arthritis Impact Measurement Scale 2 (AIMS-2) score 4.02 and 0.06 (p = 0.001). Long-term effects could only be assessed by analysing the cohort of participants who received TCA (as allocated treatment or escape treatment), due to a high proportion of non-responders in the NaCl group. The short-term beneficial effects were maintained during the follow-up phase of 12 months. Patients were satisfied with corticosteroid injection therapy and there were only a few minor side effects. CONCLUSIONS Local injection with TCA is effective and safe for treating trigger finger as compared to placebo injection. The effects of steroid injections last up to 12 months.

Impact of Mediterranean diet education versus posted leaflet on dietary habits and serum cholesterol in a high risk population for cardiovascular disease

OBJECTIVE To investigate the impact of intensive group education on the Mediterranean diet on dietary intake and serum total cholesterol after 16 and 52 weeks, compared to a posted leaflet with the Dutch nutritional guidelines, in the context of primary prevention of cardiovascular disease (CVD). DESIGN Controlled comparison study of an intervention group given intensive group education about the Mediterranean diet and a control group of hypercholesterolaemic persons given usual care by general practitioners (GPs). SETTING A socioeconomically deprived area in the Netherlands with an elevated coronary heart disease (CHD) mortality ratio. SUBJECTS Two hundred and sixty-six hypercholesterolaemic persons with at least two other CVD risk factors. RESULTS After 52 weeks, the intervention group decreased total and saturated fat intake more than the control group (net differences were 1.8 en% (95%CI 0.2-3.4) and 1.1 en% (95%CI 0. 4-1.9), respectively). According to the Mediterranean diet guidelines the intake of fish, fruit, poultry and bread increased in the intervention group, more than in the control group. Within the intervention group, intake of fish (+100%), poultry (+28%) and bread (+6%) was significantly increased after 1 year (P < 0.05). The intensive programme on dietary education did not significantly lower serum cholesterol level more (-3%) than the posted leaflet (-2%) (net difference 0.06 mmol l-1, 95%CI -0.10 to 0.22). Initially, the body mass index (BMI) decreased more in the intervention group, but after 1 year the intervention and control group gained weight equally (+1%). CONCLUSIONS Despite beneficial changes in dietary habits in the intervention group compared with the control group, after 1 year BMI increased and total fat and saturated fat intake were still too high.

High Prevalence of Concentric Remodeling in Elderly Individuals With Isolated Systolic Hypertension From a Population Survey

Echocardiographic determination of left ventricular mass index (LVMI) is shown to be valuable in the assessment of cardiovascular risk. Determination of left ventricular geometry, including concentric remodeling, provides additional prognostic information. In isolated systolic hypertension (ISH), the few echocardiographic studies available show an increased LVMI, but criteria and patient populations differ. No comparison with diastolic hypertension (DH) has been made, nor has left ventricular geometry (with concentric remodeling) been evaluated. We compared both LVMI and left ventricular geometry of newly diagnosed ISH subjects with normotensive and DH subjects, all previously untreated and from the same population. The echocardiographic LVMI of 97 previously untreated ISH subjects (4 x systolic pressure > or = 160 mm Hg, diastolic pressure < 95 mm Hg) was clearly elevated compared with values in age- and sex-matched normotensive subjects (98 and 71 g/m2, respectively; P < .001). The geometric pattern was abnormal in most ISH subjects, with a high prevalence (43%) of concentric remodeling. Both LVMI and left ventricular geometry of ISH subjects did not differ significantly from values in DH subjects (LVMI, 92 g/m2; concentric remodeling, 56%). Sex differences in LV geometry in ISH were present only with the Framingham criteria, not with the Koren criteria. This study shows a high prevalence of concentric remodeling in elderly individuals with previously untreated ISH. The increase of LVMI and abnormality in left ventricular geometry are comparable with those in DH subjects, further defining the place of ISH as a cardiovascular risk factor in the elderly. Whether there are sex differences in cardiac adaptation in ISH and whether the geometric classification can be used to adjust treatment remain to be investigated.

Randomised controlled trial of local corticosteroid injections for carpal tunnel syndrome in general practice

BackgroundCarpal tunnel syndrome is caused by entrapment of the median nerve and results in pain, tingling and numbness in the wrist and hand. It is a common condition in general practice. Effectiveness of treatment by intracarpal corticosteroid injection has never been investigated in general practice. The objective of this study was to determine if corticosteroid injections for carpal tunnel syndrome provided by general practitioners are effective.MethodsIn this study 69 participants with a clinical diagnosis of carpal tunnel syndrome were recruited from 20 general practices. Short-term outcomes were assessed in a randomised, placebo-controlled trial. Long-term results were assessed in a prospective cohort-study of steroid responders.Participants were randomised to intracarpal injections of 1 ml triamcinolonacetonide 10 mg/ml (TCA) or 1 ml NaCl (placebo). Non-responders to NaCl were treated with additional TCA injections. Main outcomes were immediate treatment success, mean score of the Symptom Severity Scale (SSS) and Functional Status Scale (FSS) of the Boston carpal tunnel questionnaire, subjective improvement and proportion of participants with recurrences during follow-up. Duration of follow-up was twelve months.ResultsThe TCA-group (36 participants) had better outcomes than the NaCl-group (33 participants) during short-term assessment for outcome measures treatment response, mean improvement of SSS-score (the mean difference in change score was 0.637 {95% CI: 0.320, 0.960; p < 0.001}) and FSS-score (the mean difference in change score was 0.588 {95% CI: 0.232, 0.944; p = 0.002}) and perceived improvement (p = 0.01). The number to treat to achieve satisfactory partial treatment response or complete resolution of symptoms and signs was 3 (95% CI:1.83, 9.72).49% of TCA-responders (17/35) had recurrences during follow-up. In the group of TCA-responders without recurrences (51%, 18/35) outcomes for SSS-score and FSS-score deteriorated during the follow-up period of 12 months (resp. p = 0.008 and p = 0.012).ConclusionsCorticosteroid injections for CTS provided by general practitioners are effective regarding short-term outcomes when compared to placebo injections. The short-term beneficial treatment effects of steroid injections deteriorated during the follow-up period of twelve months and half of the cohort of steroid-responders had recurrences.Trial registrationCurrent Controlled Trials ISRCTN53171398