Maria M. Kolar

Effect of Iyengar yoga therapy for chronic low back pain

Low back pain is a significant public health problem and one of the most commonly reported reasons for the use of Complementary Alternative Medicine. A randomized control trial was conducted in subjects with non‐specific chronic low back pain comparing Iyengar yoga therapy to an educational control group. Both programs were 16 weeks long. Subjects were primarily self‐referred and screened by primary care physicians for study of inclusion/exclusion criteria. The primary outcome for the study was functional disability. Secondary outcomes including present pain intensity, pain medication usage, pain‐related attitudes and behaviors, and spinal range of motion were measured before and after the interventions. Subjects had low back pain for 11.2±1.54 years and 48% used pain medication. Overall, subjects presented with less pain and lower functional disability than subjects in other published intervention studies for chronic low back pain. Of the 60 subjects enrolled, 42 (70%) completed the study. Multivariate analyses of outcomes in the categories of medical, functional, psychological and behavioral factors indicated that significant differences between groups existed in functional and medical outcomes but not for the psychological or behavioral outcomes. Univariate analyses of medical and functional outcomes revealed significant reductions in pain intensity (64%), functional disability (77%) and pain medication usage (88%) in the yoga group at the post and 3‐month follow‐up assessments. These preliminary data indicate that the majority of self‐referred persons with mild chronic low back pain will comply to and report improvement on medical and functional pain‐related outcomes from Iyengar yoga therapy.

Evaluation of a Wellness-Based Mindfulness Stress Reduction intervention: a controlled trial.

Purpose. To determine if participation in a Wellness-Based Mindfulness Stress Reduction intervention decreases the effect of daily hassles, psychological distress, and medical symptoms. Design. A randomized controlled trial of a stress reduction intervention with a 3-month follow-up. Setting. A university setting in West Virginia. Subjects. A total of 103 adults, with 59 in the intervention group and 44 in the control group. Eight-five percent of subjects completed the intervention. Fifty-nine percent and 61% of the intervention and control subjects completed the study, respectively. Intervention. The intervention consisted of an 8-week group stress reduction program in which subjects learned, practiced, and applied “mindfulness meditation” to daily life situations. The control group received educational materials and were encouraged to use community resources for stress management. Measures. The Daily Stress Inventory assessed the effect of daily hassles, the Revised Hopkins Symptom Checklist measured psychological distress, the Medical Symptom Checklist measured number of medical symptoms, and a Follow-up Questionnaire measured program adherence. Results. Intervention subjects reported significant decreases from baseline in effect of daily hassles (24%), psychological distress, (44%), and medical symptoms (46%) that were maintained at the 3-month follow-up compared to control subjects (repeated measures analysis of variance [ANOVA]; p < .05). Conclusions. Self-selected community residents can improve their mental and physical health by participating in a stress reduction intervention offered by a university wellness program.

Effects of Resistance vs. Aerobic Training Combined With an 800 Calorie Liquid Diet on Lean Body Mass and Resting Metabolic Rate

OBJECTIVE Utilization of very-low-calorie diets (VLCD) for weight loss results in loss of lean body weight (LBW) and a decrease in resting metabolic rate (RMR). The addition of aerobic exercise does not prevent this. The purpose of this study was to examine the effect of intensive, high volume resistance training combined with a VLCD on these parameters. METHODS Twenty subjects (17 women, three men), mean age 38 years, were randomly assigned to either standard treatment control plus diet (C+D), n = 10, or resistance exercise plus diet (R+D), n = 10. Both groups consumed 800 kcal/day liquid formula diets for 12 weeks. The C+D group exercised 1 hour four times/week by walking, biking or stair climbing. The R+D group performed resistance training 3 days/week at 10 stations increasing from two sets of 8 to 15 repetitions to four sets of 8 to 15 repetitions by 12 weeks. Groups were similar at baseline with respect to weight, body composition, aerobic capacity, and resting metabolic rate. RESULTS Maximum oxygen consumption (Max VO2) increased significantly (p<0.05) but equally in both groups. Body weight decreased significantly more (p<0.01) in C+D than R+D. The C+D group lost a significant (p<0.05) amount of LBW (51 to 47 kg). No decrease in LBW was observed in R+D. In addition, R+D had an increase (p<0.05) in RMR O2 ml/kg/min (2.6 to 3.1). The 24 hour RMR decreased (p<0.05) in the C+D group. CONCLUSION The addition of an intensive, high volume resistance training program resulted in preservation of LBW and RMR during weight loss with a VLCD.

Confidence of Graduating Internal Medicine Residents to Perform Ambulatory Procedures

AbstractOBJECTIVE: To evaluate the training of graduating internal medicine residents to perform 13 common ambulatory procedures, 3 inpatient procedures, and 3 screening examinations. DESIGN: Self-administered descriptive survey. SETTING: Internal medicine training programs associated with 9 medical schools in the eastern United States. PARTICIPANTS: Graduating residents (N=128); response rate, 60%. MEASUREMENTS AND MAIN RESULTS: The total number of procedures performed during residency, importance for primary care physicians to perform these procedures, confidence to perform these procedures, and helpfulness of rotations for learning procedures were assessed. The majority of residents performed only 2 of 13 outpatient procedures 10 or more times during residency; simple spirometry and minor wound suturing. For all other procedures, the median number performed was 5 or fewer. The percentage of residents attributing high importance to a procedure was significantly greater than the percentage reporting high confidence for 8 of 13 ambulatory procedures; for all inpatient procedures, residents reported significantly higher confidence than importance. Continuity clinic and block ambulatory rotations were not considered helpful for learning ambulatory procedures. CONCLUSIONS: Though residents in this sample considered most ambulatory procedures important for primary care physicians, they performed them infrequently, if at all, during residency and did not consider their continuity clinic experience helpful for learning these skills. Training programs need to address this deficiency by modifying the curriculum to ensure that these skills are taught to residents who anticipate a career in primary care medicine.

Confidence of Academic General Internists and Family Physicians to Teach Ambulatory Procedures

OBJECTIVE: To evaluate and compare the readiness of academic general internal medicine physicians and academic family medicine physicians to perform and teach 13 common ambulatory procedures.DESIGN: Mailed survey.SETTING: Internal medicine and family medicine residency training programs associated with 35 medical schools in 9 eastern states.PARTICIPANTS: Convenience sample of full-time teaching faculty.MEASUREMENTS AND MAIN RESULTS: A total of 331 general internists and 271 family physicians returned completed questionnaires, with response rates of 57% and 65%, respectively. Academic generalists ranked most of the ambulatory procedures as important for primary care physicians to perform; however, they infrequently performed or taught many of the procedures. Overall, compared with family physicians, general internists performed and taught fewer procedures, received less training, and were less confident in their ability to teach these procedures. Physicians’ confidence to teach a procedure was strongly associated with training to perform the procedure and performing or precepting a procedure at least 10 times per year.CONCLUSIONS: Many academic general internists do not perform or precept common adult ambulatory procedures. To ensure that residents have the opportunity to learn routine ambulatory procedures, training programs may need to recruit qualified faculty, train current faculty, or arrange for academic specialists or community physicians to teach these skills.

Patient preferences for care by general internists and specialists in the ambulatory setting

AbstractOBJECTIVE: To investigate patients’ preferences for care by general internists and specialists for common medical conditions. DESIGN: Telephone interview. SETTING: A convenience sample of general internal medicine practices at 10 eastern academic medical centers. PATIENT/PARTICIPANTS: A probability sample of 314 participants who had at least one visit with their primary care physician during the preceding 2 years. MEASUREMENTS AND MAIN RESULTS: Items addressed patients’ attitudes concerning continuity of care, preferences for care by general internists or specialists for common medical problems, and perceptions about the competency of general internists and specialists to manage these problems. Continuity was important to participants, with 63% reporting they preferred having one doctor. Respondents were willing to wait 3 or 4 days to see their regular doctor (85%) and wanted their doctor to see them in the emergency department (77%) and monitor their care while in the hospital (94%). A majority (>60%) preferred care from their regular doctor for a variety of new conditions. Though respondents valued continuity, 84% felt it was important to be able to seek medical care from any type of physician without a referral, and 74% responded that if they needed to see a specialist, they were willing to pay out-of-pocket to do so. Although most participants (98%) thought their regular doctor was able to take care of usual medical problems, the majority through that specialists were better able to care for allergies (79%) and better able to prescribe medications for depression (65%) and low-back pain (72%). CONCLUSIONS: Participants preferred to see their general internist despite their perceptions that specialists were more competent in caring for the conditions we examined. However, they wanted unrestricted access to specialists to supplement care provided by general internists.

Teaching Women's Health Skills: Confidence, Attitudes, and Practice Patterns of Academic Generalist Physicians

AbstractOBJECTIVE: This study assesses the readiness of academic general internists to perform and precept a commonly utilized women’s health examination, and procedural and management skills. DESIGN: Full-time faculty from divisions of general internal medicine and departments of family practice in 9 states reported their encounter frequency with, comfort precepting, and the importance they ascribe to several examination, procedural, and management skills relevant to women’s health care; and their attitudes toward performing the pelvic exam and obtaining a Pap smear. MEASUREMENTS AND MAIN RESULTS: A total of 331 general internal medicine physicians (GIMs) and 271 family medicine physicians (FPs) completed questionnaires, with response rates of 57% and 64%, respectively. More than 90% of GIMs and FPs indicated they were confident precepting the breast and Pap/pelvic examinations. A relatively small percentage of GIMs expressed confidence precepting the management of dysfunctional uterine bleeding (22%), initiating Depo-Provera (21%), and initiating oral contraceptives (45%), while a substantially larger percentage indicated that these skills were important to primary care practice (43%, 44%, and 85%, respectively). Although GIMs indicated they were confident precepting the Pap/pelvic exam, they were less likely than FPs to agree with the following statements: “Performing routine Pap smears is a good use of my time” (GIMs 65%, FPs 84%); “It is a waste of health care dollars for primary care physicians to refer patients to gynecologists for routine Pap/pelvic exams” (GIMs 69%, FPs 90%); “I feel very well trained to do a routine bimanual exam” (GIMs 71%, FPs 98%), and “The clinic where I practice is well equipped to do a Pap smear” (GIMs 78%, FPs 94%). CONCLUSIONS: Although most academic GIMs are confident precepting the breast and pelvic examination, only a minority are confident precepting the management of dysfunctional uterine bleeding, initiating Depo-Provera, and initiating oral contraceptives. These findings suggest that a number of academic GIMs may not be prepared or willing to perform or precept important women’s health skills.

Osteoporosis Screening: Factors Associated with Bone Mineral Density Testing of Older Women

BACKGROUND Osteoporosis is a major public health problem. Guidelines recommend osteoporosis screening, primarily with bone mineral density (BMD) testing, of all women aged > or =65 and younger women at increased risk. However, BMD testing is underused, and osteoporosis screening practices are not in compliance with guidelines. METHODS This was a retrospective cohort study of 809 women patients > or =65 years. The proportion of patients having evidence of BMD testing and factors associated with BMD testing were evaluated. RESULTS The overall proportion of patients having evidence of BMD testing was 42.9%. A higher proportion of patients from the gynecology practice (72%) had evidence of BMD testing compared with family medicine (42%), general internal medicine (36%), and the Veterans Administration practice (30%) (p < 0.0001). The proportion of patients with evidence of BMD testing was higher in patients seen by faculty (48%) than in patients seen by midlevel providers (35%) or residents (21%) (p < 0.0001) and was higher in patients of female providers (54%) than in patients of male providers (31%) (p < 0.0001). Negative associations with BMD testing were seen with increasing age and numbers of medications (p < 0.0001 and p < 0.05, respectively). The numbers of visits and numbers of total and unique ICD-9 codes were each negatively associated with BMD testing (p < 0.05, p < 0.005, and p < 0.05, respectively). In patients with commercial insurance, 48% had evidence of BMD testing vs. 25% in the rest of the subjects (p < 0.0001). The proportion of patients with evidence of BMD testing also varied by body mass index (BMI). CONCLUSIONS Consideration of factors associated with BMD testing may be useful in developing interventions to increase osteoporosis screening rates.

Implementing University-Based Wellness: A Participatory Planning Approach

Community and work-site wellness programs are increasing in prominence. However, planning and implementing such programs at large bureaucratic institutions are difficult. This project established a wellness program at a major university using a participatory planning approach that is applicable to other complex organizations. University students, faculty, staff, administrators, and retirees volunteered to participate in a 12-week planning project. The project consisted of weekly sessions designed to promote participation, ownership, and problem solving. Activities included information exchange, wellness lifestyle practice, reflection, discussion, and wellness program planning. Participants organized themselves into special task forces to identify campus health problems, barriers, and resources as well as to define goals and implementation strategies for a proposed ongoing university wellness program. A campus-wide university wellness program was implemented the following academic year. The project was effective in overcoming institutional barriers and mobilizing community resources. It is recommended that this approach be used in other settings.