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Biomedical Therapy
J o urnal o f
Volume 5, Number 2 ) 2011
Integrating Homeopathy and Conventional Medicine
Work-Related Disorders
Pathologies Associated With the Workplace Repetitive Strain Injury as a Model of Inammation
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H.P.Hoff/artbotanica iStockphoto.com/Milena Lachowicz
Contents
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I n Fo c u s
Pathologies Associated With the Workplace . . . . . . . . . . . . . . 4
W h a t E l s e I s N e w ? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Practical Protocols
Work-Related Psychological Stress and the Hypothalamic-Pituitary-Adrenal Axis . . . . . . . . . . . . . . . 16 Bioregulatory Management of Mouse Arm . . . . . . . . . . . . 20
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Around the Globe
iMosaic Integrative Medicine Conference . . . . . . . . . . . . . . . . 23
Re f r e s h Yo u r H o m o t ox i c o l o g y
Repetitive Strain Injury as a Model of Inammation . . . . . . 24
E x p a n d Yo u r Re s e a r c h K n o wl e d g e Re s e a r c h H i g h l i g h t s
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Clinical Trials: An Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 The Role of Vertigoheel as an Adjuvant Treatment in Patients With Transient Ischemic Attacks: An Observational Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Meet the Expert
Dr. Jan Kersschot . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Cover iStockphoto.com/Steve Cole
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Published by/Verlegt durch: International Academy for Homotoxicology GmbH, Bahnackerstrae 16, 76532 Baden-Baden, Germany, www.iah-online.com, e-mail: journal@iah-online.com Editor in Chief/verantwortlicher Redakteur: Dr. Alta A. Smit Editor: Dr. David W. Lescheid Managing Editor: Silvia Bartsch Print/Druck: Dinner Druck GmbH, Schlehenweg 6, 77963 Schwanau, Germany 2011 International Academy for Homotoxicology GmbH, Baden-Baden, Germany
How Work Affects Our Health

Dr. Alta A. Smit
ccording to the Merriam-Webster Dictionary, work can be dened as the activity where one exerts strength or faculties to do or perform something: a) sustained physical or mental effort to overcome obstacles and achieve an objective or result b) the labor, task, or duty that is ones accustomed means of livelihood c) a specic task, duty, function, or assignment often being a part or phase of some larger activity.1 The way we work has changed dramatically in the past 120 years, in terms of decreased working hours (from 3000 to 1500 hours per year in industrialized countries) and the introduction of technology in the workplace. The result of these changes is that the output has stayed the same, despite the fewer hours worked.2 Although we could argue that we are more affluent in our current society, there are people who believe that the hunter-gatherers were, in fact, the original affluent society, because they only needed to work 15 to 20 hours per week and the remainder of the time was leisure time.3 Despite working fewer hours than 120 years ago, the concept of negative work-life balance was introduced as early as the mid-1800s. The causes range from personal ambition and the pressure of family obligations to the accelerating pace of technology.4
According to a recent study performed by the Center for Work-Life Policy,5 50% of top corporate executives are leaving their current positions. Although 64% of workers believe that their work pressures are self-inicted, they state that it is taking a toll on them. The study also shows that 70% of US respondents and 81% of global respondents say their jobs are affecting their health. The increased use of technology has also taken its toll, and new medical diagnoses, such as mouse arm or Blackberry thumb, are recognized.6 Therefore, we dedicate this issue of the Journal of Biomedical Therapy to work-related disorders. These disorders are very good examples of dysregulation syndromes. Often chronic and insidious in nature, they may be present for a long time, until the patient nally seeks medical advice. In the focus article, we, therefore, provide an overview of the range of disorders associated with work. In the Practical Protocols, we then go more in-depth discussing mouse arm and the effect of psychological stress at work. In Refresh Your Homotoxicology, the intricate network of disturbances in repetitive strain injury is described, demonstrating the dysregulatory nature of the disease. Our research section has 2 features: the follow-up article on clinical trials and an innovative study with
Vertigoheel after transient ischemic attack. Lastly, our Meet the Expert column features Dr. Jan Kersschot, the founder of Biopuncture. This ts well in this journal because Biopuncture is one of the effective intervention methods in work disorders involving the musculoskeletal system.7 We wish you success and health in your work!
Dr. Alta A. Smit
References 1. Work. Merriam-Webster Dictionary Web site. http://www.merriam-webster.com/dictionary/work. Accessed November 8, 2011. 2. Bosch G. Working time and working time policy in Germany. http://www.jil.go.jp/ english/reports/documents/jilpt-reports/ no.7_bosch.pdf. Accessed November 8, 2011. 3. Sahlins M. The original affluent society. http://www.eco-action.org/dt/affluent. html. Accessed November 8, 2011. 4. John R, Henkel A, Rckert-John J, eds. Die Methodologien des Systems: Wie kommt man zum Fall und wie dahinter? Wiesbaden, Germany: VS Verlag; 2010. 5. Hewlett SA, Luce CB, Southwell S, Bernstein L. Seduction and Risk: The Emergence of Extreme Jobs. New York, NY: Center for WorkLife Policy; 2007. 6. Hewlett SA, Luce CB. Extreme jobs: the dangerous allure of the 70-hour workweek. Harv Bus Rev. 2006;84(12):49-59, 162. 7. Biopuncture. International Academy of Biopuncture Web site. http://www.iabp-online. com. Accessed November 8, 2011.
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Journal of Biomedical Therapy 2011 ) Vol. 5, No. 2
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Pathologies Associated With the Workplace

Introduction Work-related disorders (WRDs) comprise physical and psychosocial disorders that have their origin in the workplace. Work-related physical disorders include disorders involving the musculoskeletal system, dermatitis, and deafness; in addition, they include diseases that have been shown or suspected to have been caused by a workplace activity or environment. Musculoskeletal disorders (MSDs), such as lower back pain and repetitive strain injury, are the most common WRDs in Europe.1 Work-related psychosocial disorders (eg, burn-out syndrome and anxiety) generally arise from stress caused or made worse by the individuals work or work environment. Work stress combines the harmful physical and emotional responses that occur when the job requirements do not match the capabilities, resources, or needs of the worker. Work stress can lead to poor mental and physical health and injury. Acute reactions, such as stress and fatigue; adverse health behavior, such as smoking; and chronic outcomes, such as cardiovascular disorders and MSDs, are associated with extended and irregular hours.2 High exposure to a combination of physical and psychosocial work risk factors produces the greatest risk of developing self-reported musculoskeletal complaints compared with
A Review Article
By Wulf Saur, MD Orthopedic Surgeon exposure to either physical or psychosocial factors alone.3 The working environment continues to change with the world economy, technical developments, and better use of resources; this change has led to changes in the balance between physical and mental activity.4 Developments to reduce the amount of heavy physical work aim to minimize the risk of physical injury. In contrast, new working environments that are characterized by greater part-time and contract work, greater workload demands, lack of time, more uncontrollable factors, and job insecurity have resulted in an increase in mental and emotional stressors,4 psychological ill health, and sickness absence in staff.5 This article reviews WRDs, covering incidence/prevalence, cost to society and the individual, types of WRDs and associated risk factors, pathology, intervention strategies, and treatment options. The Size of the Problem Number of Workers Affected Data from the 2007 Labour Force Survey indicate that 8.6% of the European Union workforce (average, 27 countries [EU-27]) reported one or more work-related health problems.6 Of those EU-27 workers reporting a problem caused or made worse by work, 50% reported that their daily activity was affected to some extent and 22% reported that
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their daily activity was affected considerably. Sick leave was taken by 62.0% of EU-27 workers, and long-term sick leave (longer than 1 month) was taken by 27% of these workers. The 2005 European Working Conditions Survey shows that 34% of EU-27 employees report that work affects their health.6 Estimates from EU Member States indicate that more than 600 million working days are lost because of work-related ill health each year in Europe.7 Of all WRDs, work-related stress and work-related MSDs (WRMSDs*) are the leading occupational health problems in the EU.8 In Great Britain, MSDs have consistently been the most commonly reported WRDs in the national Labour Force Survey.6 From 2009 to 2010, the estimated prevalence of people who worked in the past year and who experienced an MSD, caused or made worse by their current or past work, equated to 1900 (1.9%) per 100,000 people; the estimated incidence rate was 630 (0.63%) per 100,000 people. Stress has consistently been the second most commonly reported type of work-related illness in the national Labour Force Survey in Great Britain.6 From 2009 to 2010, the estimated prevalence of people who worked in the past year and experienced stress caused or made worse by their current or past work equated to 1500 (1.5%) per 100,000 people; the estimated incidence was
* WRMSDs are also designated in the literature as WMSDs.
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iStockphoto.com/Dmitriy Shironosov
Working environments and workimpact on peoples health.
related activities can have a signicant
780 (0.78%) per 100,000 people. Records of the US Department of Labour Bureau of Labor Statistics report that, in 2009, the number of injury and illness cases was 3,277,700; cases involving days away from work totaled 965,000. The number of sprains, strains, and tears composed 379,340 cases; and cases involving the back (including the spine and spinal cord) totaled 195,150.9 A comprehensive study10 of the US workforce indicated that the state of health of the US workforce is deteriorating. The percentage of employees rating their overall health as excellent declined from 34% in 2002 to 28% in 2008, whereas the percentage of people reporting that they did not experience minor health problems in the past month declined from 36% to 29%. Such conditions can be caused or aggravated by stress, which may be reected by the 41% of employees experiencing 3 or more indicators of stress sometimes, often, or very often. A review11 of illness in the workplace indicated that 30.8% of Canadians reported that most days at work were either a bit or extremely stressful and that those individuals who experienced work-related stress appear to be at a higher risk of mental health problems. Economic Costs The economic cost of WRDs is huge. Costs to business include lost production; sick leave compensation
and insurance costs; loss of experienced staff and costs of recruiting and training new staff; and the effects of discomfort or ill health on work quality. Estimates from EU Member States indicate that the economic costs of all work-related ill health range from 2.6% to 3.8% of the gross national product.12 A high proportion (up to 50%) of the costs was for MSDs, estimated to represent between 0.5% and 2% of the gross net product.13 Data show that, from 2009 to 2010, an estimated 9.3 million working days were lost through WRMSDs in Great Britain.6 There are also high costs to primary and secondary care in terms of consultations, treatment, and hospitalization.14 Costs to Workers and Their Families In addition, WRDs affect the quality of life of those affected both at work and in their home life. For example, in Great Britain, subjective costs of WRMSDs, including reduced quality of life (eg, pain and suffering), concern caused to family and friends, and the loss of functioning from incapacity, are estimated at approximately 2.2 billion.15 The nancial cost (ie, loss of income) to each individual forced to stop working permanently until retirement age because of a work-related illness is estimated to be, on average, 51,000.15 The link between unemployment and health is well established.16,17
Evidence supports a positive association between unemployment and increased mortality and between unemployment and increased physical or mental morbidity.16,17 Generally, studies16 report a positive association between national unemployment rates and rates of overall mortality and mortality due to cardiovascular disease and suicide. Compared with people with employment, self-reported health is lower during periods of unemployment and use of health services is increased.16,17 In addition, nonworking young people generally report more somatic and psychological symptoms during recession than boom.18 The Relationship Between Work and WRDs Work-related disorder is multifactorial,19 indicating that several risk factors contribute to causing such diseases. However, it is reasonable to assume that working conditions and exposures may also aggravate, accelerate, or exacerbate disease. Risk factors contributing to WRDs include physical, work organizational, psychosocial, and individual factors (Table 1). Physical Risk Factors Musculoskeletal disorders cover a broad range of WRDs, which vary in severity from minor aches and pains to more serious medical con-
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ditions requiring time off from work and medical treatment. They also vary in specicity from carpal tunnel syndrome, with well-dened signs and symptoms, to nonspecic pain or discomfort, without evidence of a clear specic disorder (Table 2). They mainly affect the back, neck, shoulders, and upper limbs, but they can also affect the lower limbs. According to a 2005 European survey, at least 60 million workers reportedly experience MSDs in Europe, with up to 25% of the workers in the EU-27 reporting back pain and 23% reporting muscular pain.20 Approximately 17% of European workers complain of muscular pains in their arms and legs.7 Most WRMSDs are cumulative, resulting from repeated exposure to loads over a long period, but they can also be acute traumas (eg, fractures) that occur during an accident.1 Heavy lifting, awkward postures, and excessive repetition are the most commonly reported biomechanical risk factors, with at least reasonable evidence for causing WRMSDs.21 In Europe, it is estimated that 62% of workers are exposed to repetitive hand or arm movements, 46% report working in painful or tiring positions for at least a quarter of their working time, 18% of blue-collar workers report having to move heavy loads all or almost all of the time, and 50% of women and 45% of men work on computers every day.20 Systematic reviews have been consistent in their ndings in reporting a positive relationship between physical workplace risk factors and WRMSDs. Physical features of the working environment that are cited as risk factors for WRDs include limited space, local or wholebody exposure to cold or excessive heat, poor lighting, and high noise levels (Table 1). Such stressors cause the body to tense, affect body posture, and may cause distractions and accidents. For example, employees increasingly work with computers, resulting in a new epidemic of work-related neck and upper limb disorders. In addition to the manual aspects of the work, workers using display screen equipment are frequently exposed to lack of space, noise, poor lighting, and poor ergonomics.20 From 2009 to 2010, an estimated 21,000 individuals in Great Britain who worked in the past 12 months were experiencing hearing problems that they believed to be work related.6 Symptoms of sick building syndrome, such as inammation, respiratory infections, and asthma symptoms, are linked to low ventilation rates in offices and molds have been implicated in their development.22,23 Occupational exposure to chemicals, dusts, fumes, smoke, or gas is a well-known risk factor for WRDs (Table 3). The onset of many of these diseases does not occur until years after the exposures; therefore, most new cases or deaths largely reect heavy exposures in the past and mainly occur in individuals who have retired.6 More recently, inhalation of laser printer toner dust has been shown to result
Table 1: Risk Factors Contributing to Work-Related Disorders

Physical Factors Physical aspects of work Loads Force application Repetition of movements Direct mechanical pressure on body tissues Body vibrations Awkward and static postures Acute trauma Work environment Extreme temperatures Poor lighting High noise levels Limited space Organizational and Psychosocial Factors Demanding work at a high pace Lack of control over the tasks performed; low levels of autonomy Low levels of job satisfaction; repetitive and monotonous work Shift work; time patterns Fatigue How workers perceive the work organization; lack of support from colleagues, supervisors, and managers Payment systems Individual Factors Medical history Physical and mental capacity Age Obesity Smoking Lifestyle and work style Coping mechanisms Previous experiences Expectations Self-confidence
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Exposure to chemicals, dusts, fumes, smoke, or gas
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Table 2. Types of Work-Related Musculoskeletal Conditions According to Body Region
Upper Limb
Lower Limb Nonspe c i f i c Wo r k-Rel ated
Back and Neck Di so rder s Back Low back pain Neck Nonradiating neck pain (ie, tension neck syndrome)
Overuse syndrome Cumulative trauma disorder Repetitive strain injury Chronic upper limb pain syndrome
None
S pe c i f i c Wo r k-Rel ated Shoulder Painful shoulder Bursitis Tendon-related disorders Tendinitis of the shoulder Bicipital tendinitis Infraspinatus tendinitis Supraspinatus tendinitis Subscapularis tendinitis Rotator cuff lesions Impingement syndrome Frozen shoulder Elbow Epicondylitis Lateral epicondylitis Medial epicondylitis Beat elbow Olecranon bursitis Hand and wrist Carpal tunnel syndrome Cubital tunnel syndrome Radial tunnel syndrome Ulnar tunnel syndrome Pronator and anterior interosseous syndrome Tenosynovitis De Quervains tenosynovitis Intersection syndrome Beat hand Hand and wrist pain Hand-arm vibration syndrome Vibration-induced white nger Hip and thigh Osteoarthritis Piriformis syndrome Trochanteritis Hamstring strains Sacroiliac pain Knee and lower leg Beat knee/hyperkeratosis Bursitis Meniscal lesions Osteoarthritis Patellofemoral pain syndrome Prepatellar tendinitis Shin splints Infrapatellar tendinitis Stress fractures Ankle and foot Achilles tendinitis Blisters Foot corns Hallux valgus Hammer toes Pes traverse planus Plantar fasciitis Sprained ankle Stress fractures Varicose veins Venous disorders
Di so rder s Spinal disk problems (eg, hernias and spondylolisthesis) Muscle strain Radiating neck pain
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in submesothelial deposition of carbon nanoparticles in the peritoneum, affecting the respiratory health of persons exposed.24 The cancer burden study25 estimated that 5.3% of all cancer-related deaths were attributable to occupation in 2005 and that associated incidence estimates were 4.0% of cancer registrations. The study showed that 56% of cancer registrations in men (mainly mesotheliomas and lung, stomach, bladder, and nonmelanoma skin cancers) are attributable to work in the construction industry and that 54% of cancer registrations in women (ie, breast cancer) are attributable to shift work. Psychosocial and Organizational Factors Psychosocial factors include an individuals subjective perceptions regarding aspects of the work organization, such as perceived demands of the work, job satisfaction, impending redundancies/unwanted job transfers, conicts and threats within the role, and relationships with and degree of support from managers and work colleagues. Psychosocial risk factors have the potential for causing psychological and physical damage to health because they can place individuals under considerable stress. Stress is often related directly to the work specications or to relationships with people at work, and conicts with managers or colleagues may increase as work becomes more pressured.26,27 Higher levels of perceived job stress were found among subjects with a higher education level and those who were administrators or managers.26 Critical reviews28,29 have found that psychosocial risk factors are also related to WRMSDs. Work organization factors describe characteristics of the work system, such as hours worked, work-rest cycles (shifts), culture, management style, control over the work, level of autonomy, and payment systems. Shift workers vary greatly in their capacity to adjust to the atypical work schedules and tolerate circadian misalignment. The desynchronization that occurs in circadian rhythms, with respect to sleep cycles, predisposes employees to coronary heart disease, impaired glucose and lipid metabolism, gastrointestinal disturbances, increased risk of breast cancer, and poor pregnancy outcomes.30,31 Individual Factors An individuals risk of WRDs relates to his or her specic demographic characteristics, medical history and physical capacity, and factors such as beliefs, attitudes, and personality traits. The amount of stress experienced by a person also depends on various factors, such as his or her behavioral type, personal pattern of coping with demands, attitude towards unpredictable and difficult situations, previous experiences, self-condence in his or her own abilities, and lifestyle.4,32 Other work factors related to WRMSDs may include rewards concerning money and career opportunities.3,32 In Europe, upper limb disorders are reported to affect more female than male workers, mainly because of the type of work they do (eg, hand-intensive tasks); for example, 35% of
Table 3. Diseases Associated With Occupational Exposure to Chemicals, Dusts, Fumes, Smoke, or Gasa
Organ Lung Occupational Exposure Inhalation of fumes, chemicals, and dusts Inhalation and retention in the lungs of mineral dusts Disease Chronic obstructive pulmonary disease Asbestosis (asbestos bers) Pneumoconiosis (coal dust) Silicosis (crystalline silica) Inhalation of cotton dust Inhalation of organic material Skin Absorption of lead Contact with soaps and cleaners, wet work, and rubber chemicals and materials Byssinosis Allergic reactions (eg, farmers lung) Lead poisoning Contact dermatitis
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a
Data from HSE (Health and Safety Executive).6
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Physical stressors (eg, repetitive

movements, heavy loads, or vibrations) are a risk factor for work-related musculoskeletal disorders such as repetitive strain injury.
female workers perform permanent repetitive work compared with 31% of male workers.7 Other factors thought to be important in the observed sex differences are anthropometric differences (eg, body size and strength), which might disadvantage the female worker in work systems in which no such consideration has been taken. Moreover, there is evidence that previous injury predisposes workers to further injury, particularly when they engage in little or no physical activity outside of work.33 It is generally reported that older workers are more predisposed to WRMSDs than younger workers because of natural body aging and because older workers have worked (and, therefore, been exposed) for a longer period. Thus, older workers in Europe report more WRMSDs, with an average of 25% of people aged 15 to 24 years and 35% aged 55 years or older reporting backache.7 Advanced age, female sex, and obesity (ie, high body mass index) are reported as risk factors for work-related lower limb disorders (ie, hip and knee osteoarthritis).33 In addition, individuals psychological fear-avoidance beliefs have been identied as predictors of progression to chronic disorders and prolonged work disability.34 Fear-avoidance beliefs about work in individuals with acute low back pain were signicant predictors of 4-week disability and work status,
even after controlling for initial levels of pain intensity, physical impairment and disability, and therapy type received. Link Between WRMSDs and Stress Several epidemiological studies3,35 have implicated exposure to physical and psychosocial risk factors in the workplace in the development of WRMSDs. Perceived job stress has also been implicated as an intermediate factor between high exposure to physical and psychosocial work risk factors and the reporting of some MSDs.36 In addition, once a MSD is present, psychosocial factors (eg, depression and maladaptive pain responses) play a role in the transition from acute to chronic pain and in the development of disability.37 A comprehensive review3 of the literature found most evidence arising from cross-sectional studies, which have shown a positive association between stress and WRMSD but make it difficult to determine causation. However, there are a few prospective epidemiological studies providing support for a predictive relationship between symptoms of psychological strain and MSD. For example, prospective studies have shown a positive association between symptoms of stress/psychological strain and lower back problems and symptoms of stress/ psychological strain and neck/ shoulder problems. The review not-
ed that prospective studies have also shown no relationship between stress/psychological strain and lower back problems and work-related stress and self-reported hand/wrist problems. Pathology of WRDs Mechanisms underlying the association between work stress and disease, such as cardiovascular disease, possibly involve direct activation of neuroendocrine responses to stressors and indirect activation through unhealthy behaviors (eg, smoking, alcohol use, and lack of physical exercise).38 The cardiovascular risk factors found to be most common in managers were obesity, hypertension, and elevated levels of blood glucose and low-density lipoprotein, whereas cigarette smoking, familial congestive heart disease, and a high brinogen level were more common in physical workers.39 There is evidence that stress in humans has increased, both physically and psychosocially, as a result of the ever-growing demands of work.40 Stimulation of the hypothalamicpituitary-adrenal axis by stressors leads to the release of glucocorticoids, mainly cortisol, in the blood,41 with effects on the metabolism of adipose tissue.42 Globalization and modernization create work situations that impose neurogenic stress that, in turn, increases the impact of
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glucocorticoids.40 There is evidence that the increase in knowledgebased work and the decrease of quality/duration of sleep increase cortisolemia and glycemia instability, resulting in an increase in food intake, a reduction in energy expenditure, and body fat gain.40 Studies investigating the association between work, psychosocial factors, and carotid atherosclerosis have yielded mixed results, from ndings of no association between work-related stress and increased carotid atherosclerosis43 to signicantly greater progression of carotid atherosclerosis in men with high work demand/low economic reward than in more advantaged men44 and a positive correlation between job demands and coronary artery intimamedia thickness in men but not in women.45 The nding of no signicant correlation between perceived work-related stress and preclinical atherosclerosis (ie, carotid artery intima-media thickness) was considered the result of somatization of stress by individuals with a low level of perceived work-related stress.46 Thus, their stress is not perceived at the conscious level, but it leads to somatic effects, such as intimamedia thickening.46 Work-related stressful situations induce emotional disorders that may affect both neuroendocrine and immune systems.47 Reduced reactivity to mitogens and/or decreased blood natural killer (NK) cytotoxic activity was reported in unemployed workers or in those with a high perception of job insecurity and/or job stress. Occupational stress (eg, from disruption of circadian timing in night shifts) was reportedly associated with an increased incidence of autoimmune disorders.47 Stress from sleep deprivation and sleep loss is directly connected to a reduction of NK cells and increased inammatory responses,48,49 and job stress has been shown to exert a negative impact on immune outcomes.50-52 Overtime work was associated with a decrease of NK cell counts but not with other immune indicators, such as NK cell cytotoxicity, the NK cell cytotoxicity to NK cell ratio, and T and B cells.53 The decrease of NK cell counts suggests a dampened innate immune defense system. The decrease in NK cell counts by overtime work may be the result of redistribution of NK cells between lymphoid organs and the periphery, without losing cytotoxic capacity,53 or the down-regulation of -adrenergic receptors on NK cells.54 This study also showed an association between overtime work and increased body mass index, reduced sleep hours, and job satisfaction; thus, the NK cell decrease was believed to be the result of a combination of factors. Prevention Strategies Generally, it is believed that illness and disability associated with nonspecic MSDs can be managed only according to a biopsychosocial model that includes biological (ie, physical or mental health factors, such as physiological dysfunction), psychological (ie, personal/psychological factors, such as behavior, beliefs, coping strategies, and emotions), and social (ie, social context, pressures, and constraints on functioning, such as culture and social interaction) dimensions that inuence functioning.55 The model perceives functioning and disability as a dynamic interaction between the individuals health condition and contextual factors that include both personal/psychological and social/ occupational factors.55 The approach is appropriate in WRMSD management strategies because, although biological considerations are important, psychosocial factors may be
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more inuential for occupational outcomes.56 Therefore, interventions designed to reduce the risk of selfreported WRMSDs should consider the degree of exposure to physical and psychosocial work risk factors and the workers individual stress reactions.3 Despite risk reduction, interventions that focus on physical and/or psychosocial workplace risk factors only may not be entirely successful in preventing WRMSDs. Some workers may still continue to experience these disorders because of musculoskeletal damage caused by other pathological pathways, such as individual psychological reactions.3 Recently, a Cochrane review57 concluded that workplace interventions were effective for reducing sickness absence among workers with MSD but were not effective for improving health outcomes among these individuals. There is a considerable variety of potential interventions for the prevention of WRMSDs, depending on the problems in each sector of working life. A systematic review20 of the scientic evidence reported from 2000 to 2006 on the effectiveness of measures to prevent work-related MSDs classied the interventions into 4 main categories: organizational and administrative (eg, rest breaks) technical, engineering, or ergonomic (eg, tools, techniques, and mechanical aids) personal (eg, protective equipment) behavioral (eg, training and working postures) Case studies20 drawn from a range of occupations and sectors of work across Europe showed that interventions to tackle the risks of MSDs can reduce the rate of sick leave due to MSD, improve the satisfaction and motivation of workers, improve working conditions and overall safety, and positively inuence fac-
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Table 4. Pharmacological Therapies Used in the Treatment of Musculoskeletal Disordersa

Type Corticosteroids Effect Pain relief and reduction of inammation Action A wide array of activity, affecting most immune system cells Up-regulate expression of antiinammatory proteins and downregulate expression of proinammatory proteins Inhibit conversion of phospholipids into arachidonic acid Cause profound and varied metabolic effects (eg, exacerbate diabetes mellitus)
Nonsteroidal anti-inammatory drugs Muscle relaxants
Most commonly used for relief of mild-to-moderate pain Adjunctive therapy for nociceptive pain and chronic pain syndromes
Inhibit prostaglandin synthesis by decreasing COX enzyme activity Thought to act centrally at the level of the spinal cord, brainstem, or cerebrum, by interfering with neurotransmission Act on the central nervous system and interact with specic receptor sites to interfere with pain impulses Essential to quality patient care, ensuring patient comfort, enabling physical therapy regimens, and limiting the likelihood of a chronic pain syndrome
Narcotic analgesics
Pain control
Tricyclic antidepressants
Used to treat depression as an adjunct to pain medications and for sedation when sleep is disrupted Used to treat anxiety and for sedation when sleep is disrupted
Prolong the effects of neurotrans mitters by inhibiting the reuptake of norepinephrine and serotonin Act primarily by facilitating -aminobutyric transmission in limbic regions of the brain
Anxiolytic agents
Abbreviation: COX, cyclooxigenase. a Data from Laker et al.59
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tors such as process capacity, production output, and product. Treatment Options The management of MSDs is a clinical and an occupational issue that requires proper workplace policies, attitudes, and interventions. Many treatment options are commonly used in daily practice for specic and nonspecic disorders.58 Nonpharmacological treatments comprise therapies such as rest, exercise, physical therapy, behavioral therapy, occupational therapy, and ergonomic interventions. The pharmacological medication (Table 4) includes treatment for physical symptoms (eg, corticosteroids, nonsteroidal anti-inammatory drugs, muscle relaxants, and analgesics) and for psychiatric symptoms (eg, antidepressants).59 Alternative and complementary therapies (eg, acupuncture and transcutaneous electrical nerve stimulation and bioregulating medicines) may also be effective. Regarding combination treatments, bioregulating medicines can provide a holistic approach. Combinations of treatments are commonly used, whereas a surgical intervention may be an option when conservative treatments fail.58 A review58 of treatment studies for repetitive strain injuries concluded that no strong recommendation for any therapeutic intervention could be made. However, there is support for the use of some therapies in the treatment of specic overuse injuries: nonspecific disorders: exercise therapy (relieves symptoms and improves the activities of daily living) and manual therapy (eg, osteopathy or chiropracty) carpal tunnel syndrome: local corticosteroid injections and oral corticosteroids (both short-term), wrist splint, and open carpal tunnel surgery release lateral epicondylitis (tennis elbow): topical and oral nonsteroidal anti-inammatory drugs (both short-term), corticosteroid injections, ultrasonography, and percutaneous tenotomy or formal open release neck pain: exercise and mobilization plus exercise shoulder pain: subacromial and intra-articular corticosteroid injections, physiotherapy (ie, manual treatment and exercise), and surgical arthroscopic decompression The bioregulatory medical treatment of WRDs will be included in other articles in this issue of the journal, including an outline of the treatment of repetitive strain injury with Traumeel and practical protocols on treating mouse arm and work-related stress disorders. Conclusions The management of WRDs remains challenging, with a need to address physical and/or psychosocial workplace risk factors and individual psychological reactions. There is a growing body of evidence for a link between MSDs and mental and emotional stress. The complexity and interactive nature of these conditions require a comprehensive multidisciplinary approach if their management is to be effective. A holistic approach, considering the commonalities and interactions between WRMSDs and stress, may result in reducing both conditions.|
2. Johnson JV, Lipscomb J. Long working hours, occupational health and the changing nature of work organization. Am J Ind Med. 2006;49(11):921-929. 3. Devereux J, Rydstedt L, Kelly V, et al. The role of work stress and psychological factors in the development of musculoskeletal disorders: the stress and MSD study. Research Report 273. Health and Safety Executive, 2004. http://www.hse.gov.uk/research/rrpdf/rr273.pdf. Accessed November 3, 2011. 4. von Onciul J. ABC of work related disorders: stress at work. BMJ. 1996;313(7059):745748. 5. Mitchie S, Williams S. Reducing work related psychological ill health and sickness absence: a systematic literature review. Occup Environ Med. 2003;60(1):3-9. 6. HSE (Health and Safety Executive). Health and safety statistics 2009/10. http://www. hse.gov.uk/statistics/index.htm. Published 2010. Accessed March 30, 2011. 7. EASHW (European Agency for Safety and Health at Work). Work-related musculoskeletal disorders in Europe. FACTS 3. 2000a. http://osha.europa.eu/en/publications/ factsheets/3. Accessed November 3, 2011. 8. European Commission. Eurostat. http://epp. eurostat.ec.europa.eu/portal/page/portal/ statistics/search_database. Published 2011. Accessed November 3, 2011. 9. US Department of Labour Bureau of Labor Statistics. Injuries, illnesses, and fatalities. http://www.bls.gov/iif/. Accessed November 3, 2011. 10. Aumann K, Galinsky E. The state of health in the American workforce: does having an effective workplace matter? Families & Work Institute, 2009. http://www.familiesand work.org/site/research/reports/HealthRe port.pdf. Accessed November 3, 2011. 11. Dewa CS, Lesage A, Goering P, Caveen M. Nature and prevalence of mental illness in the workplace. Healthc Pap. 2004;5(2):1225. http://www.longwoods.com/content/ 16820. Accessed July 19, 2011. 12. EASHW (European Agency for Safety and Health at Work). Economic impact of occupational safety and health in the Member States of the European Union. Agency report, 1998. http://osha.europa.eu/en/pub lications/reports/302. Accessed November 3, 2011. 13. EASHW (European Agency for Safety and Health at Work). Work-related neck and upper limb musculoskeletal disorders: summary of agency report. FACTS 5. 2000b. http://osha.europa.eu/en/publications/ factsheets/5. Accessed November 3, 2011. 14. Holmberg SA, Thelin AG. Primary care consultation, hospital admission, sick leave and disability pension owing to neck and low back pain: a 12-year prospective cohort study in a rural population. BMC Musculoskelet Disord. 2006;7:66. 15. EASHW (European Agency for Safety and Health at Work). Inventory of socio-economic information about work-related musculoskeletal disorders in the Member States of the European Union. FACTS 9. 2000c. http://osha.europa.eu/en/publications/ factsheets/9. Accessed November 3, 2011.
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References 1. EASHW (European Agency for Safety and Health at Work). Introduction to work-related musculoskeletal disorders. FACTS 71. http://osha.europa.eu/en/publications/ factsheets/71. Published 2007. Accessed November 3, 2011.
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16. Jin R, Shah CP, Svoboda TJ. The impact of unemployment on health: a review of the evidence. Can Med Assoc J. 1995;153(5):529540. 17. NHS. Unemployment and health. http:// www.nhsfife.scot.nhs.uk/fifepublichealth dataset/Unemployment%20and%20health %20nal.doc. Accessed November 3, 2011. 18. Novo M, Hammarstrm A, Janlert U. Do high levels of unemployment inuence the health of those who are not unemployed? A gendered comparison of young men and women during boom and recession. Social Sci Med. 2001;53(3):293-303. 19. Novak CB, Mackinnon SE. Multilevel nerve compression and muscle imbalance in workrelated neuromuscular disorders. Am J Ind Med. 2002;41(5):343-352. 20. EASHW (European Agency for Safety and Health at Work), Podniece Z. Work-related musculoskeletal disorders: prevention report. http://osha.europa.eu/en/publications/re ports/en_TE8107132ENC.pdf. Published 2008. Accessed November 3, 2011. 21. da Costa BR, Vieira ER. Risk factors for work-related musculoskeletal disorders: a systematic review of recent longitudinal studies. Am J Ind Med. 2010;53(3):285-323. 22. Sundell J, Levin H, Nazaroff WW, et al. Ventilation rates and health: multidisciplinary review of the scientic literature. Indoor Air. 2011;21(3):191-204. 23. Straus DC. The possible role of fungal contamination in sick building syndrome. Front Biosci (Elite Ed). 2011;3:562-580. 24. Theegarten D, Boukercha S, Philippou S, Anhenn O. Submesothelial deposition of carbon nanoparticles after toner exposition: case report. Diagn Pathol. 2010,5:77. 25. Rushton L, Bagga S, Bevan R, et al. Occupation and cancer in Britain. Br J Cancer. 2010;102(9):1428-1437. 26. Cheng Y, Guo YL, Yeh WY. A national survey of psychosocial job stressors and their implications for health among working people in Taiwan. Int Arch Occup Environ Health. 2001;74(7):495-504. 27. Oxenstierna G, Magnusson Hanson LL, Widmark M, Finnholm K, Stenfors C, Elofsson S, Theorell T. Conicts at work: the relationship with workplace factors, work characteristics and self-rated health [published online ahead of print June 21, 2011]. Ind Health. doi:10.2486/indhealth.MS1171. 28. Bugajska J, Jedryka-Gral A, Gasik R, Zonierczyk-Zreda D. Acquired musculoskeletal dysfunction syndromes in workers in the light of epidemiological studies. Med Pr. 2011;62(2):153-161. 29. Cao L, DU WW, Wang S, et al. The interactive effect of job task and psychosocial factors on work-related musculoskeletal disorders. Zhonghua Lao Dong Wei Sheng Zhi Ye Bing Za Zhi. 2011;29(3):176-179. 30. Boivin DB, Tremblay GM, James FO. Working on atypical schedules. Sleep Med. 2007;8(6):578-589. 31. Mosendane T, Mosendane T, Raal FJ. Shift work and its effects on the cardiovascular system. Cardiovasc J Afr. 2008;19(4):210-215. 32. Chorus AM, Miedema HS, Wevers CW, van der Linden S. Work factors and behavioural coping in relation to withdrawal from the labour force in patients with rheumatoid arthritis. Ann Rheum Dis. 2001;60(11):10251032. 33. Okunribido O. Lower limb MSD. Scoping work to help inform advice and research planning. Research Report 706. Health and Safety Executive, 2009. http://www.hse.gov. uk/research/rrpdf/rr706.pdf. Accessed November 3, 2011. 34. Fritz JM, George SZ, Delitto A. The role of fear-avoidance beliefs in acute low back pain: relationships with current and future disability and work status. Pain. 2001;94(1):7-15. 35. Punnett L, Wegman DH. Work-related musculoskeletal disorders: the epidemiologic evidence and the debate. J Electromyogr Kinesiol. 2004;14(1):13-23. 36. Bongers PM, Kremer AM, ter Laak J. Are psychosocial factors, risk factors for symptoms and signs of the shoulder, elbow, or hand/wrist? A review of the epidemiological literature. Am J Ind Med. 2002;41(5):315342. 37. Menzel NN. Psychosocial factors in musculoskeletal disorders. Crit Care Nurs Clin North Am. 2007;19(2):145-153. 38. Chandola T, Britton A, Brunner E, et al. Work stress and coronary heart disease: what are the mechanisms? Eur Heart J. 2008;29(5):640-648. 39. Bugajska J, Michalak JM, Jedryka-Gral A, Sagan A, Konarska M. Coronary heart disease risk factors and cardiovascular risk in physical workers and managers. Int J Occup Saf Ergon. 2009;15(1):35-43. 40. Huneault L, Mathieu M, Tremblay A. Globalization and modernization: an obesogenic combination. Obes Rev. 2011;12(5):e64-e72. 41. Bjorntorp P. Do stress reactions cause abdominal obesity and comorbidities? Obes Rev. 2001;2:73-86. 42. Eswar P, Kenneth R, Shang-Jin W, Khose MA. Effects of nancial globalisation on developing countries: some empirical evidence. Econ Polit Wkly. 2003;38(41):4319-4330. 43. Rosvall M, Ostergren PO, Hedblad B, Isacsson SO, Janzon L, Berglund G. Work-related psychosocial factors and carotid atherosclerosis. Int J Epidemiol. 2002;31(6):1169-1178. 44. Lynch J, Krause N, Kaplan GA, Salonen R, Salonen JT. Workplace demands, economic reward, and progression of carotid atherosclerosis. Circulation. 1997;96(1):302-307. 45. Hintsanen M, Kivimaki M, Elovainio M, et al. Job strain and early atherosclerosis: the cardiovascular risk in young Finns study. Psychosom Med. 2005;67:740-747. 46. Bugajska J, Widerszal-Bazyl M, Radkiewicz P, et al. Perceived work-related stress and early atherosclerotic changes in healthy employees. Int Arch Occup Environ Health. 2008;81(8):1037-1043. 47. Boscolo P, Di Gioacchino M, Reale M, Muraro R, Di Giampaolo L. Work stress and innate immune response. Int J Immunopathol Pharmacol. 2011;24(suppl 1):51S-54S.
48. Shakhar K, Valdimarsdottir HB, Guevarra JS, Bovbjerg DH. Sleep, fatigue, and NK cell activity in healthy volunteers: signicant relationships revealed by within subject analyses. Brain Behav Immun. 2007;21(2):180-184. 49. van Leeuwen WM, Lehto M, Karisola P, et al. Sleep restriction increases the risk of developing cardiovascular diseases by augmenting proinammatory responses through IL-17 and CRP. PLoS One. 2009;4(2):e4589. 50. Morikawa Y, Kitaoka-Higashiguchi K, Tanimoto C, et al. A cross-sectional study on the relationship of job stress with natural killer cell activity and natural killer cell subsets among healthy nurses. J Occup Health. 2005;47(5):378-383. 51. Boscolo P, Di Donato A, Di Giampaolo L, et al. Blood natural killer activity is reduced in men with occupational stress and job insecurity working in a university. Int Arch Occup Environ Health. 2009;82(6):787-794. 52. Nakata A, Takahashi M, Irie M, Swanson NG. Job satisfaction is associated with elevated natural killer cell immunity among healthy white-collar employees. Brain Behav Immun. 2010;24(8):1268-1275. doi:10.1016/j. bbi.2010.05.004. 53. Nakata A, Takahashi M, Irie M. Association of overtime work with cellular immune markers among healthy daytime white-collar employees [published online ahead of print July 16, 2011]. Scand J Work Environ Health. doi: 10.5271/sjweh.3183. 54. Dimsdale JE, Mills P, Patterson T, Ziegler M, Dillon E. Effects of chronic stress on beta-adrenergic receptors in the homeless. Psychosom Med. 1994;56(4):290-295. 55. Waddell G. Preventing incapacity in people with musculoskeletal disorders. Br Med Bull. 2006;77-78:55-69. 56. Burton AK, Kendall NA, Pearce BG, et al. Management of work-relevant upper limb disorders: a review. Occup Med (Lond). 2009;59(1):44-52. 57. van Oostrom SH, Driessen MT, de Vet HC, et al. Workplace interventions for preventing work disability. Cochrane Database Syst Rev. 2009;(2):CD006955. 58. van Tulder M, Malmivaara A, Koes B. Repetitive strain injury. Lancet. 2007;369(9575): 1815-1822. 59. Laker SR, Sullivan WJ, Strum S. Overuse Injury. Available at: http://emedicine.med scape.com/article/313121-overview. Acces sed November 3, 2011.
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) What Else is New?

workplace improves employee alert iStockphoto.com/Xebeche iStockphoto.com/Izvorinka Jankovic
Blue-enriched white light in the
ness, performance, and concentration.
the risk of both musculoskeletal disorders and psychovegetative
Working longer hours increases
complaints.
Office Lighting Affects Productivity

The right lighting can help workers be more productive! In this study on the use of blue-enriched white light in an office, 104 white-collar workers were studied over 8 weeks. Two types of light were used for 4 weeks each: blue-enriched white light (17,000 K) and white light (4000 K). For the 94 workers included in the nal analysis, many factors were signicantly improved with the use of blue-enriched white light, including alertness, positive mood, performance, evening fatigue, concentration, and daytime sleepiness (P < .001 for all); eye discomfort (P = .002); irritability (P = .004); and nighttime sleep quality (P = .016). Therefore, individuals in charge of offices should consider the use of positive lighting as a potential benet to both their workers and their offices. Scand J Work Environ Health. 2008;34(4):297-306.
Graveyard Shift Leads to Increased Injuries

In this Canadian study, the Survey of Labour and Income Dynamics was used to determine trends in injury by shift from 1996 to 2006. Work injury was determined by receipt of workers compensation. The results of the study showed that work injury decreased overall from 1996 to 2006, but not in night shift workers. Findings indicated the following: (1) night shift was associated with injury for both women (odds ratio [OR], 2.04) and men (OR, 1.91) and (2) a rotating shift was associated with injury for women only (OR, 2.29). Thus, the study concluded that regulatory agencies and employers should determine and help alleviate the issues that lead
to increased work injury in these shift workers.
Working Overtime Associated With Health Complaints

Dont work too much! Its not just what your friends say! This study used information from a 2000 European survey on working conditions. Statistics were used to examine the association between working hours and health impairments. It appears that health complaints, including musculoskeletal disorders and psychovegetative complaints, were more prevalent in those who worked longer hours! The factors that affect the relationship between working hours and health are both individual (eg, age) and situational (eg, shift work). The association between number of working hours and workers health is consistent and may affect numerous conditions. Therefore, longer work hours are denitely not necessarily recommended! Chronobiol Int. 2006;23(6):1305-1316.
Scand J Work Environ Health. 2011;37(1):54-61.

F O R P RO F E S S I ONA L U S E ON LY
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The information contained in this journal is meant for professional use only, is meant to convey general and/or specic worldwide scientic information relating to the products or ingredients referred to for informational purposes only, is not intended to be a recommendation with respect to the use of or benets derived from the products and/or ingredients (which may be different depending on the regulatory environment in your country), and is not intended to diagnose any illness, nor is it intended to replace competent medical advice and practice. IAH or anyone connected to, or participating in this publication does not accept nor will it be liable for any medical or legal responsibility for the reliance upon or the misinterpretation or misuse of the scientic, informational and educational content of the articles in this journal. The purpose of the Journal of Biomedical Therapy is to share worldwide scientic information about successful protocols from orthodox and complementary practitioners. The intent of the scientic information contained in this journal is not to dispense recipes but to provide practitioners with practice information for a better understanding of the possibilities and limits of complementary and integrative therapies. Some of the products referred to in articles may not be available in all countries in which the journal is made available, with the formulation described in any article or available for sale with the conditions of use and/or claims indicated in the articles. It is the practitioners responsibility to use this information as applicable and in a manner that is permitted in his or her respective jurisdiction based on the applicable regulatory environment. We encourage our readers to share their complementary therapies, as the purpose of the Journal of Biomedical Therapy is to join together like-minded practitioners from around the globe. Written permission is required to reproduce any of the enclosed material. The articles contained herein are not independently veried for accuracy or truth. They have been provided to the Journal of Biomedical Therapy by the author and represent the thoughts, views and opinions of the articles author.
) What Else is New?

computer use include eyestrain,
Possible adverse effects of headaches, dry eye, and
blurred vision.
Prolonged exposure to
workplace noise results in increased incidence of coronary heart disease and hypertension.
Noise Exposure Affects Cardiovascular Health

Excess noise at work is a real occupational health issue. This study used a national US sample to determine the relationship between self-reported occupational noise exposure and coronary heart disease (CHD) and hypertension. The sample included 6307 individuals who completed the National Health and Nutrition Examination Survey 1999-2004, aged 20 years and older, and employed when the interview was conducted. When compared with those never exposed to workplace noise, individuals with long-term occupational noise exposure experienced a 2- to 3-fold increase of angina pectoris (odds ratio, 2.91), CHD (odds ratio, 2.40), and isolated diastolic hypertension (odds ratio, 2.23). The study was adjusted for the following covariates: race/ethnicity, educational attainment, annual family income, leisure time, physical activity, cigarette smoking status, alcohol drinking, and hearing loss. One specic nding was that the relationship between noise and angina pectoris, myocardial infarction, and CHD was strong for those younger than 50 years, male, and current smokers. The issue of workplace noise exposure deserves further attention. Occup Environ Med. 2011;68(3):183190.
Toner Dust Causes Abdominal Symptoms

Laser printers may cause ill respiratory effects on individuals. These printers emit carbon nanoparticles (CNPs), and individuals may inhale the CNPs from toner dust. Previous data indicate that office workers with long-term exposure to toner dust have more radiographic lung abnormalities, temporary coughing, and sputum production. The present case report described the experience of a 33-year-old female office worker who had intermittent abdominal pain, weight loss, and diarrhea. Several tests were performed to determine the reason for her adverse symptoms. The results of laparoscopy showed black spots in the peritoneum, the results of scanning and transmission electron microscopy showed submesothelial aggregates of CNPs (diameter, 31-67 nm), and colon biopsy results showed inammatory bowel disease and signs of Crohn disease. However, there were no dust deposits. The authors concluded that CNPs were transported by lymphatic and blood vessels after inhalation. In addition, the effects of toner dust on the respiratory system should be further examined. Diagn Pathol. 2010;5(1):77.
Visual Problems Linked to Computer Use

Even kindergarteners use computers! The Western world relies on and uses computers 24 hours a day, 7 days a week. Computers are used at home and at work, for play and performance. Unfortunately, use of these sophisticated machines can result in adverse effects. This study examined the visual problems that result from use of computers, a syndrome termed computer vision syndrome (CVS). According to this study, between 64% and 90% of computer users are affected by the following eye problems: eyestrain, headaches, ocular discomfort, dry eye, diplopia, and blurred vision. Oculomotor anomalies and dry eye were explored as the main causes of CVS. Unfortunately, there are few efficacious treatments for decreasing the symptoms of CVS. Therefore, additional studies are necessary to determine the physiological aspects of CVS. Then, the proper treatments can be used by practitioners to help patients become more comfortable and effective during computer use. Ophthalmic Physiol Opt. 2011. doi: 10.1111/j.1475-1313.2011.00834.x.
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iStockphoto.com/spxChrome
) Practical Protocols
Work-Related Psychological Stress and the Hypothalamic-PituitaryAdrenal Axis

By David W. Lescheid, PhD, ND tisol, but the mineralocorticoids (eg, aldosterone) and adrenal androgens (eg, dehydroepiandrosterone and androstenedione) are also affected in this pathway. Negative feedback loops between these hormones assist with providing regulated control of the stress response.14,15 Other major contributors to the control of the HPA axis include cytokines (eg, interleukin 1,16 interleukin 6, and tumor necrosis factor 17) and numerous other hormones, including oxytocin, atrial natriuretic peptide (synthesized and released from cardiomyocytes in the heart atrium), and prolactin.18 Other stress-related molecules that are primarily associated with the immediate response by the sympathetic nervous system include the catecholamines epinephrine (also termed adrenaline) and norepinephrine (also termed noradrenaline).19 Many of the messenger molecules associated with the HPA axis, and their receptors, have been found in other areas of the body, most notably the gastrointestinal tract20 and the nervous and immune systems.21 Indeed, because of the extensive overlap between the individual systems, an overarching term for this eld of study is psychoneuroimmunology.22 Prolonged activation of the HPA axis results in persistently high levels of cortisol that have wideranging effects on numerous body systems to inuence psychological and physical pathology.23 It is well-
The impact of work-related physical stress on the initiation and perpetuation of different disease processes has been well documented in the scientic literature and discussed in other articles within this issue of the Journal of Biomedical Therapy.
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t is also becoming increasingly evident that the psychological stress associated with unhealthy work environments substantially contributes to the development of many different conditions and diseases, including insomnia,1 anxiety and depression,2 cognitive impairment,3 irritable bowel syndrome,4 visceral obesity,5 metabolic syndrome,6 cardiovascular disease7 (including coronary heart disease8), skin disorders,9 and infertility.10,11 Persistent psychosocial stress also contributes to the development of physical signs and symptoms of disease, but this article will focus only on some of the other effects of prolonged exposure to inadequate working environments. In particular, it will provide a brief summary of the hypothalamic-pituitary-adrenal (HPA) axis and the negative effects of persistently high levels of cortisol. One of the pioneers in investigating the impact of chronic stress on the human organism was Dr. Hans Selye, who proposed in the mid-
1930s12 that there were distinct phases of compensation that occurred with continued exposure to high levels of physical and psychosocial stress. He termed the overall response the general adaptation syndrome, which included the consecutive phases of alarm, resistance or adaptation, and exhaustion.13 Further research has largely supported his initial work and delineated some of the major anatomical and biochemical pathways and messengers involved as well as their impact on different metabolic pathways. The most commonly accepted cornerstone of the stress response is the HPA axis. This includes the primary messenger molecules of corticotrophin-releasing hormone (CRH) and vasopressin (also termed arginine vasopressin), synthesized and released from the brain hypothalamus; adrenocorticotrophic hormone from the anterior pituitary gland; and the corticosteroid family of hormones from the cortex of the adrenal glands. The most commonly referred to corticosteroid is the glucocorticoid corJournal of Biomedical Therapy 2011 ) Vol. 5, No. 2
known that the levels of circulating cortisol wax and wane along with the circadian rhythm, with an early morning peak of 1 to 2 hours before waking (between 3 and 5 AM) and a late-night nadir of approximately 12 PM.15 An abnormal rhythm, in particular an enhanced increase on waking, was positively associated with persistent job stress and poorer health outcomes.24 More recently it has been shown that there is also an ultraradian glucocorticoid cycle that is important to maintain receptor sensitivity and additional biological signaling.25,26 Cortisol has also recently been shown to play a predominant role in resetting the circadian clocks of other cyclical hor mones and messaging molecules.27 Continued disruptions to normal daily rhythms are associated with the development of numerous pathologies including depression,28 immune system disorders,29 hormone-related cancers (including breast cancer30), and rheumatoid arthritis.31 These rhythms can be disrupted by several different stressors, including shift work and light at night,32 and the psychological stress of persistently inadequate working environments. It is apparent that acute levels of stress and the resultant high levels of cortisol can have discombobulating effects, including impaired memory.33-35 Furthermore, what is becoming increasingly established in the medical literature is that poorly managed persistently high levels of stress can have long-term impacts on the health of the central nervous system and negative effects on human cognition.36 There also is increasing evidence of direct communication between the HPA axis and the hypothalamic-pituitary-gonadal axis.37 High levels of cortisol suppress circulating testosterone levels,38 whereas testosterone also feeds back to help regulate CRH-related activity on the HPA axis in men.39 High levels of CRH inhibit gonadotropin-releasing hormone and, therefore, reproduction function. They also increase levels of somatostatin and, therefore, affect secretion of growth hormone, thyroid-releasing hormone, and thy-
Table. Bioregulatory Management of Work-Related Stress

DET-Phase Multiple systems and levels of effects possible Basic and/or Symptomatic Neurexan/Nervoheel D&D Regulation Therapya Basic detoxication and drainage: Detox-Kitb In chronic cases: advanced supportive detoxication and drainagec Optional Glandula suprarenalis suis-Injeel (to support the functions of the adrenal glands )
IM CTOS
Tonsilla compositumd Cerebrum compositum Coenzyme compositum Ubichinon compositum
Tonico-Injeel (if there is marked physical and mental exhaustion) Testis compositum (in men) Ovarium compositum (in women)
Notes: It is important to determine any modiable diet and lifestyle factors and address them if possible. A foundation of healthful nutrition and eating habits, sustained periods of restful sleep, and regular stress management activities are important foundational interventions to support any changes imposed by medications. Dosages: Basic therapy: Neurexan, 10 drops or 1 tablet 3 times per day; Nervoheel, 1 tablet 3 times per day. Regulation therapy: tablets, 1 tablet 3 times per day; drops, 10 drops 3 times per day; ampoules, 1 ampoule of each medication, 1 to 3 times per week. Detox-Kit, 30 drops of each medication in 1.5 L of water (drink throughout the day). Optional therapy: 1 ampoule of each appropriate medication, 1 to 3 times per week.
Abbreviations: CTOS, cellular, tissue, and organ support; D&D, detoxication and drainage; DET, Disease Evolution Table; IM, immunomodulation. a Antihomotoxic regulation therapy consists of a 3-pillar approach: D&D, IM, and CTOS. b The Detox-Kit consists of Lymphomyosot, Nux vomica-Homaccord, and Berberis-Homaccord. Berberis-Homaccord is also suggested to support the adrenal glands. c Advanced supportive detoxication and drainage consists of Hepar compositum (liver), Solidago compositum (kidney), and Thyreoidea compositum (connective tissue). d Tonsilla compositum contains Hypothalamus suis and Cortex glandulae suprarenalis suis.
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roid-stimulating hormone. This means that CRH indirectly inuences the roles of these hormones on reproduction health and developments.40 A brain-gut axis also exists with several potential avenues of bidirectional communication including the cholinergic anti-inammatory pathway41 and the mucosal mast cells.42 Consistently high levels of psychological stress alter motility and secretion (and, therefore, digestive and absorptive capacity) as well as perception of pain in the gastrointestinal tract, as seen in irritable bowel syndrome,43 as well as contribute to the development of hyperpermeability.44 Other diseases share this mucosal distress as an underlying etiological factor that could be initiated or perpetuated by persistently high psychological stress.45 Finally, because of the documented impact of persistent mental emotional stress on the immune system, there is potential for increased infections and immune-related disorders.46 For example, continued periods of psychosocial stress, such as that from repetitive overtime work in white collar employees,47 can affect the number and ability of natural killer cells to develop and respond appropriately.48,49 Natural killer cells play a critical role in our rst line of defense against viruses and in the development of neoplastic cells (ie, cancer).50 Prolonged periods of elevated glucocorticoids also can inuence the secretion of cytokines controlling the T-helper cell type 1/T-helper cell type 2 balance, with a tendency to induce a shift towards a T-helper cell type 2dominant state.51 This affects the ability to cope with infections and also increases the likelihood of developing disorders associated with atopy, including allergies, asthma, and eczema. The bodys ability to cope with psychosocial stress stemming from unhealthy work environments is largely an individual process; therefore, it is difficult to quantify the magnitude and length of exposure needed to provoke a pathological response. Furthermore, there is a well-conceptualized, but relatively poorly dened, concept of a personal threshold, at which each of the factors that affect the HPA axis might not be able to have an impact on its own; they only have an impact once they collectively exceed a persons compensatory abilities. This idea of an individuals personal reserve and the cumulative buildup necessary to produce signs and symptoms is termed the allostatic load.52 There are several different potential objective markers that can be used to indicate whether a person is experiencing chronic stress. These markers include plasma and salivary cortisol levels (in particular, a loss or exaggeration of the normal rhythms), levels of urinary catecholamines, and serum levels of hemoglobin A1C, testosterone, and brinogen.53 Medical interventions and lifestyle coping strategies that can minimize the impact of persistently high levels of work-related stress can provide a foundation that helps reduce current signs and symptoms of disease and prevent any future development. Mainstream medical therapies include pharmaceutical drugs, such as selective serotonin reuptake inhibitors, manual therapies (eg, massage), and psychotherapeutic approaches, including cognitive-behavioral interventions, different types of meditation,54 and other forms of therapy from mind-body medicine.55,56 More traditional medical approaches include acupuncture; different forms of body work; and balneotherapy, such as neutral baths. They also include herbal medicines with well-documented abilities to reduce the stress response, including Panax ginseng (Korean ginseng), Passiora incarnata (passionower), Eleutherococcus senticosus (Siberian ginseng), Glycyrrhiza glabra (licorice), Withania somnifera (Ashwagandha), Rhodiola rosea (rhodiola), Valeriana officinalis (Valerian), Matricaria chamomilla (German chamomile), and nutritional medicine, including phosphatidyl serine, magnesium, theanine (from green tea extracts), L-tryptophan, and melatonin.57 Bioregulatory Medicine also has some effective and safe medications that can be used as part of a stress management system to provide immediate relief and prevent progression into more serious disease. A therapy protocol is shown in the Table.|
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References 1. Jansson-Frjmark M, Lundqvist D, Lundqvist N, Linton SJ. Psychosocial work stressors for insomnia: a prospective study on 50-60-yearold adults in the working population. Int J Behav Med. 2007;14(4):222-228. 2. Kawano Y. Association of job-related stress factors with psychological and somatic symptoms among Japanese hospital nurses: effect of departmental environment in acute care hospitals. J Occup Health. 2008;50(1):79-85. 3. Sandstrm A, Peterson J, Sandstrm E, et al. Cognitive decits in relation to personality type and hypothalamic-pituitary-adrenal (HPA) axis dysfunction in women with stress-related exhaustion. Scand J Psychol. 2011;52(1):71-82. 4. Tach Y, Brunnhuber S. From Hans Selyes discovery of biological stress to the identication of corticotropin-releasing factor signaling pathways: implication in stress-related functional bowel diseases. Ann N Y Acad Sci. 2008;1148:29-41. 5. Kyrou I, Tsiogos C. Chronic stress, visceral obesity and gonadal dysfunction. Hormones (Athens). 2008;7(4):287-293. 6. Kyrou I, Chrousos GP, Tsigos C. Stress, visceral obesity, and metabolic complications. Ann N Y Acad Sci. 2006;1083:77-110. 7. Brotman DJ, Golden SH, Wittstein IS. The cardiovascular toll of stress. Lancet. 2007;370(9592):1089-1100. 8. Chandola T, Britton A, Brunner E, et al. Work stress and coronary heart disease: what are the mechanisms? Eur Heart J. 2008;29(5):640-648.
9. Magnavita N, Elovainio M, Heponiemi T, Magnavita AM, Bergamaschi A. Are skin disorders related to work strain in hospital workers? a cross-sectional study [published online ahead of print July 28, 2011]. BMC Public Health. 2011;11(1):600. doi:10.1186/1471-2458-11-600. 10. Tsigos C, Chrousos GP. Hypothalamic-pituitary-adrenal axis, neuroendocrine factors and stress. J Psychosom Res. 2002;53(4):865871. 11. El-Helaly M, Awadalla N, Mansour M, ElBiomy Y. Workplace exposures and male infertility: a case-control study. Int J Occup Med Environ Health. 2010;23(4):331-338. 12. Selye H. A syndrome produced by diverse nocuous agents: 1936. J Neuropsychiatry Clin Neurosci. 1998;10(2):230-231. 13. Selye H. Forty years of stress research: principal remaining problems and misconceptions. Can Med Assoc J. 1976;115(1): 53-56. 14. Guyton AC, Hall JE. Adrenocortical hormones. In: Guyton AC, Hall JE, eds. Textbook of Medical Physiology. 11th ed. Philadelphia, PA: Elsevier; 2006:944-960. 15. Berne RM, Levy MN. Adrenal cortex. In: Berne RM, Levy MN, eds. Principles of Physiology. 3rd ed. St Louis, MO: Mosby; 2000:559-571. 16. Turnbull AV, Rivier CL. Regulation of hypothalamic-pituitary-adrenal axis by cytokines: actions and mechanisms of action. Physiol Rev. 1999;79(1):1-71. 17. Dunn AJ. Cytokine activation of the HPA axis. Ann N Y Acad Sci. 2000;917:608-617. 18. McCann SM, Antunes-Rodrigues J, Franci CR, Anselmo-Franci JA, Karanth S, Rettori V. Role of the hypothalamic pituitary adrenal axis in the control of the response to stress and infection. Braz J Med Biol Res. 2000;33(10):1121-1131. 19. Berne RM, Levy MN. Adrenal medulla. In: Berne RM, Levy MN, eds. Principles of Physiology. 3rd ed. St Louis, MO: Mosby; 2000:572-578. 20. Stengel A, Tach Y. Neuroendocrine control of the gut during stress: corticotropin-releasing factor signaling pathways in the spotlight. Annu Rev Physiol. 2009;71:219-239. 21. Ziemssen T, Kern S. Psychoneuroimmunology: cross-talk between the immune and nervous systems. J Neurol. 2007;254(suppl 2):II8-II11. 22. Irwin MR. Human psychoneuroimmunology: 20 years of discovery. Brain Behav Immun. 2008;22(2):129-139. doi:10.1016/j. bbi.2007.07.013. 23. Michaud K, Matheson K, Kelly O, Anisman H. Impact of stressors in a natural context on release of cortisol in healthy adult humans: a meta-analysis. Stress. 2008;11(3):177-197. 24. Chida Y, Steptoe A. Cortisol awakening response and psychosocial factors: a systematic review and meta-analysis. Biol Psychol. 2009;80(3):265-278. doi:10.1016/j.biopsycho.2008.10.004. 25. Sarabdjitsingh RA, Conway-Campbell BL, Leggett JD, et al. Stress responsiveness varies over the ultradian glucocorticoid cycle in a brain-region-specic manner. Endocrinology. 2010;151(11):5369-5379. doi:10.1210/ en.2010-0832. 26. McMaster A, Jangani M, Sommer P, et al. Ultradian cortisol pulsatility encodes a distinct, biologically important signal. PLoS One. 2011;6(1):e15766. 27. Son GH, Chung S, Kim K. The adrenal peripheral clock: glucocorticoid and the circadian timing system. Front Neuroendocrinol. 2011;32(4):451-465. 28. Boyce P, Barriball E. Circadian rhythms and depression. Aust Fam Physician. 2010;39(5):307-310. 29. Lange T, Dimitrov S, Born J. Effects of sleep and circadian rhythm on the human immune system. Ann N Y Acad Sci. 2010;1193:48-59. 30. Davis S, Mirick DK. Circadian disruption, shift work and the risk of cancer: a summary of the evidence and studies in Seattle. Cancer Causes Control. 2006;17(4):539-545. 31. Cutolo M, Villaggio B, Otsa K, Aakre O, Sulli A, Seriolo B. Altered circadian rhythms in rheumatoid arthritis patients play a role in the diseases symptoms. Autoimmun Rev. 2005;4(8):497-502. 32. Davis S, Mirick DK, Stevens RG. Night shift work, light at night, and risk of breast cancer. J Natl Cancer Inst. 2001;93(20):1557-1562. 33. Taverniers J, Van Ruysseveldt J, Smeets T, von Grumbkow J. High-intensity stress elicits robust cortisol increases, and impairs working memory and visuo-spatial declarative memory in Special Forces candidates: a eld experiment. Stress. 2010;13(4):323-333. 34. Kirschbaum C, Wolf OT, May M, Wippich W, Hellhammer DH. Stress- and treatmentinduced elevations of cortisol levels associated with impaired declarative memory in healthy adults. Life Sci. 1996;58(17):14751483. 35. Oei NY, Everaerd WT, Elzinga BM, van Well S, Bermond B. Psychosocial stress impairs working memory at high loads: an association with cortisol levels and memory retrieval. Stress. 2006;9(3):133-141. 36. Lupien SJ, Maheu F, Tu M, Fiocco A, Schra mek TE. The effects of stress and stress hormones on human cognition: implications for the eld of brain and cognition. Brain Cogn. 2007;65(3):209-237. 37. Viau V. Functional cross-talk between the hypothalamic-pituitary-gonadal and -adrenal axes. J Neuroendocrinol. 2002;14(6):506513. 38. Cumming DC, Quigley ME, Yen SS. Acute suppression of circulating testosterone levels by cortisol in men. J Clin Endocrinol Metab. 1983;57(3):671-673. 39. Rubinow DR, Roca CA, Schmidt PJ, et al. Testosterone suppression of CRH-stimulated cortisol in men. Neuropsychopharmacology. 2005;30(10):1906-1912. 40. Tsigos C, Chrousos GP. Hypothalamic-pituitary-adrenal axis, neuroendocrine factors and stress. J Psychosom Res. 2002;53(4):865871. 41. Tracey KJ. Physiology and immunology of the cholinergic antiinammatory pathway. J Clin Invest. 2007;117(2):289-296. 42. Farhadi A, Fields JZ, Keshavarzian A. Mucosal mast cells are pivotal elements in inammatory bowel disease that connect the dots: stress, intestinal hyperpermeability and inammation. World J Gastroenterol. 2007;13(22):3027-3030. 43. Katiraei P, Bultron G. Need for a comprehensive medical approach to the neuro-immunogastroenterology of irritable bowel syndrome. World J Gastroenterol. 2011;17(23):27912800. 44. Lambert GP. Stress-induced gastrointestinal barrier dysfunction and its inammatory effects. J Anim Sci. 2009;87(14)(suppl):E101E108. 45. Lescheid DW. Intestinal permeability and its role in disease. J Biomed Ther. 2009;3(2):411. 46. Calcagni E, Elenkov I. Stress system activity, innate and T helper cytokines, and susceptibility to immune-related diseases. Ann N Y Acad Sci. 2006;1069:62-76. 47. Nakata A, Takahashi M, Irie M. Association of overtime work with cellular immune markers among healthy daytime white-collar employees [published online ahead of print July 16, 2011]. Scand J Work Environ Health. 2011;pii:3183. doi:10.5271/sjweh.3183. 48. Boscolo P, Di Gioacchino M, Reale M, Muraro R, Di Giampaolo L. Work stress and innate immune response. Int J Immunopathol Pharmacol. 2011;24(suppl 1):51S-54S. 49. Boscolo P, Di Donato A, Di Giampaolo L, et al. Blood natural killer activity is reduced in men with occupational stress and job insecurity working in a university. Int Arch Occup Environ Health. 2009;82(6):787-794. 50. Roitt I, Brostoff J, Male D. Cells of the innate immune system. In: Roitt I, Brostoff J, Male D, eds. Immunology. 6th ed. London, England: Harcourt; 2001:21-22. 51. Elenkov IJ. Glucocorticoids and the Th1/Th2 balance. Ann N Y Acad Sci. 2004;1024:138146. 52. Stewart JA. The detrimental effects of allostasis: allostatic load as a measure of cumulative stress. J Physiol Anthropol. 2006;25(1):133145. 53. Hansen AM, Larsen AD, Rugulies R, Garde AH, Knudsen LE. A review of the effect of the psychosocial working environment on physiological changes in blood and urine. Basic Clin Pharmacol Toxicol. 2009;105(2):73-83. doi:10.1111/j.1742-7843.2009.00444.x 54. Manocha R, Black D, Sarris J, Stough C. A randomized, controlled trial of meditation for work stress, anxiety and depressed mood in full-time workers. Evid Based Complement Alternat Med. 2011;2011:960583. doi:10.1155/2011/960583 55. van der Klink JJ, Blonk RW, Schene AH, van Dijk FJ. The benets of interventions for work-related stress. Am J Public Health. 2001;91(2):270-276. 56. Ruotsalainen J, Serra C, Marine A, Verbeek J. Systematic review of interventions for reducing occupational stress in health care workers. Scand J Work Environ Health. 2008;34(3):169-178. 57. Head KA, Kelly GS. Nutrients and botanicals for treatment of stress: adrenal fatigue, neurotransmitter imbalance, anxiety, and restless sleep. Alt Med Rev. 2009;14(2):114-140.
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Bioregulatory Management of Mouse Arm

By Natalie C. Tsolakis, MDipH, MTechC
Computer use has progressed extremely rapidly in recent years, both on the work front and in the home.1,2 It has been estimated that two-thirds of employees in industrialized countries use a computer on a daily basis and that 1 of 5 uses a computer at least three-quarters of the total work time.3
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he proliferation of computers in the workplace has also coincided with an increase in the number of people reporting work-related musculoskeletal disorders (WMSDs) in the neck and upper limb.4,5 After receiving relatively minimal attention throughout the rst half of the 20th century, WMSDs have become one of the main focuses in the area of occupational disease prevention, in particular forearm or upper limb WMSDs.5 Conditions such as nger extensor and exor tendonitis, carpal tunnel syndrome, and neck-shoulder myofascial pain account for more than 60% of the reported occupational illnesses in the United States4 and 45% in Europe.5 They are also the most commonly self-reported work-related illnesses in the United Kingdom, with upper limb disorders being the second highest.6 Women are generally more affected than men in all countries.4,7 In addition to the direct nancial costs of medical treatment, loss of workdays, and retraining new em-
ployees, the indirect costs include high absenteeism, high turnover of staff, poor quality of work, and low employee morale.6 Forearm pain or upper limb WMSDs have been the subject of controversy, in terms of the risks connected with exposure to the repetitive motions of computer use and the clinical terminology and diagnostic criteria commonly used.8 Recent studies9 conclude that there is a moderate, but consistent, association between computer use and hand/arm symptoms. Some symptoms may be consistent with specic clinical diagnoses (eg, carpal tunnel syndrome, lateral epicondylitis, or De Quervain syndrome) and are type I work-related upper limb disorders; however, in 50% of reported cases, the symptoms are nonspecic (eg, myalgia).9 This group of specic and nonspecic symptoms is placed under a variety of labels, including repetitive strain injury, cumulative trauma disorder, work-related upper extremity disorder, and type II work-related
upper limb disorders; these symptoms may simply be referred to as mouse arm.3,8-10 Current hypotheses ascribe the symptoms of type II work-related upper limb disorders or mouse arm to muscle/tendon/soft tissue damage, neurogenic disorders, or psychogenic causes presumed to arise from biomechanical and/or psychosocial stressors.8-10 Although the exact etiology and pathophysiology are not completely understood, it is clear that the use of a computer requires interaction between the user and the keyboard and/or other input devices and a monitor, which all involve awkward postures, high repetition, static load, forceful exertions, and localized contact stress.2,5 In people whose working time with computers exceeds 6 hours per day, there is a strong association with neck and upper limb disorders. However, the elbow, arm, or wrist/ hand disorders of frequent mouse users are only moderately greater than those of computer users who worked without computer mice.11 The nonoptimal position of the mouse (ie, not within the span of the shoulders and away from the midline of the body) results in mouse users working with the arm unsupported, the shoulder abducted and externally rotated, and the arm in forward exion.2,10-12 The repetitive motion of typing and dragging the mouse may overload the neck, shoulder, arm, hand muscles, and
Table. Bioregulatory Treatment for Mouse Arm
DET-Phase Mesodermal Basic and/or Symptomatic Traumeel (this is suitable for symptomatic treatment and immunomodulation) D&D Regulation Therapya Basic detoxication and drainage: Detox-Kitb Traumeel Coenzyme compositum* Ubichinon compositum* Optional Neurexan (or Nervoheel) (for nervous restlessness and sleep disturbances) Rhododendroneel (location on the forearm, especially with sensitivity to weather changes)
Musculodermal Inammation
IM CTOS
Cimicifuga-Homaccord (resistant to well-indicated therapy) Spascupreel (for muscle spasms)
Notes: Specic clinical diagnoses (eg, carpal tunnel syndrome, lateral epicondylitis, or De Quervain syndrome) must be excluded with the relevant physical examination (eg, joint range of motion, muscle weakness, or pain areas), orthopedic tests (eg, Phalen or Finkelstein test), neurological examination (eg, Tinel sign), and appropriate investigations (eg, electromyography or ultrasonography).1 Dosages: Basic therapy: Traumeel, 10 drops or 1 tablet 3 times per day or 1 ampoule injected into localized pain points 1 to 3 times per week. In acute conditions, the dosage can be increased up to 30 drops 3 times per day or 1 ampoule per day. Traumeel cream can also be liberally applied to the affected area 3 to 4 times per day. Regulation therapy: tablets, 1 tablet 3 times per day; drops, 10 drops 3 times per day; ampoules, 1 ampoule of each medication, 1 to 3 times per week. Detox-Kit, 30 drops of each medication in 1.5 L of water (drink throughout the day). Optional therapy: For nervousness and sleep disturbances, prescribe Neurexan, 1 tablet or 10 drops 3 times per day. For location on the forearm, especially with sensitivity to weather changes, prescribe Rhododendroneel. Begin with an initial massive dose of 10 drops every 15 minutes to a maximum of 8 doses and then reduce to 10 drops 2 to 4 times per day. In cases that are resistant to well-indicated therapies, prescribe Cimicifuga-Homaccord. In acute disorders, prescribe 10 drops every 15 minutes for 2 hours or 1 ampoule per day. In general, prescribe 10 drops 3 times per day or 1 ampoule 1 to 3 times per week. For muscle spasms and pain, prescribe Spascupreel. In acute disorders, begin with an initial massive dose of 1 tablet every 15 minutes for a maximum of 8 doses or 1 ampoule per day. In general, prescribe 1 tablet 3 times per day or 1 ampoule 1 to 3 times per week. Suppositories: In acute conditions, prescribe 1 suppository every hour. In general, prescribe 1 suppository 2 to 3 times per day.
Abbreviations: CTOS, cellular, tissue, and organ support; D&D, detoxication and drainage; DET, Disease Evolution Table; IM, immunomodulation. a Antihomotoxic regulation therapy consists of a 3-pillar approach: D&D, IM, and CTOS. b The Detox-Kit consists of Lymphomyosot, Nux vomica-Homaccord, and Berberis-Homaccord.
joints, resulting in cumulative trauma (ie, the muscles and soft tissues of the forearm become irritated and swollen, together with the surrounding tendons, resulting in painful tendonitis).1,3 These structures may then compress nearby nerves, causing ischemic neurophysiological changes. Progressive reduction in nerve conduction then leads to transient increases in the sensation, numbness, and tingling, which are then followed by weakness and, in advanced cases, diminished coordi* In Canada, Ubicoenzyme may be substituted.
nation, loss of strength, and hand/ wrist pain.1,3 Because there is no consensus on appropriate selection of physical tests, diagnosis can be delayed, unfortunately leading to the mouse arm also becoming a chronic condition. This is then further complicated by the fact that somatization (ie, the physical representation of psychological disorders) may act as a possible confounder or effect modier in this condition.3,8,10
Treatment has been reported to be somewhat unfocused and unsatisfactory, with hospital admission rarely needed and physiotherapy giving dubious benet.1,10,13 Initial management and prevention are based on modication of ergonomics (eg, alternative keyboard supports, mouse and tool redesign, adequate seating, and correction of work surface heights), with appropriate periods of rest and job rotation.1,2,6,14 Keeping hands warm, performing frequent upper limb and neck stretches
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iStockphoto.com/fatihhoca
The term mouse arm describes a type of repetitive strain injury that occurs in frequent computer users.
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and exercises, maintaining a neutral wrist position, paying attention to whole body posture, and even alternating activity between the preferred and nonpreferred hands have reduced the load on the preferred upper limb.6 The ergonomic education/intervention must be combined with medical treatment (ie, oral nonsteroidal anti-inammatory drugs and corticosteroid injections into the target area).14 Vitamin B6, acupuncture, and massage are also reported as treatment options, as is attending to any environmental, socio cultural, and psychological factors that play a role in this disorder.1 It is evident that patients with mouse arm will have a unique clinical picture that can be challenging to treat. Combining the ergonomic changes, together with patient education, various strapping techniques (eg, kinesio and/or rigid types), and the use of bioregulating medicines in oral, cream/gel, and injection forms, can make treating this condition more manageable and yield greater success rates. Patient compliance in making the necessary ergonomic changes is vital to the successful management of this condition. In combination with the other treatment modalities, a simple mouse arm trauma induced by improper working conditions can take between 2 and 12 weeks to resolve. A bioregulatory protocol for the treatment of mouse arm is shown in the Table.|
References 1. Ming Z, Zaproudina N. Computer use related upper limb musculoskeletal (ComRULM) disorders. Pathophysiology. 2003;9(3):155160. 2. Cook C, Burgess-Limerick R, Papalia S. The effect of wrist rests and forearm support during keyboard and mouse use. Int J Ind Ergon. 2004;33(5):463-472. 3. Jepsen JR, Thomsen G. A cross-sectional study of the relation between symptoms and physical ndings in computer operators. BMC Neurol. 2006;6:40. doi:10.1186/14712377-6-40. 4. Karlqvist L, Bernmark E, Ekenvall L, Hagberg M, Isaksson A, Rost T. Computer mouse and track-ball operation: similarities and differences in posture, muscular load and perceived exertion. Int J Ind Ergon. 1999;23(3):157-169. 5. Colombini D, Occhipinti E. Preventing upper limb work-related musculoskeletal disorders (UL-WMSDS): new approaches in job (re)design and current trends in standardization. Appl Ergon. 2006;37(4):441-450. 6. Ackland T, Hendrie G. Training the nonpreferred hand for ne motor control using a computer mouse. Int J Ind Ergon. 2004;35(2):149-155. 7. Won EJ, Johnson PW, Punnett L, Dennerlein JT. Upper extremity biomechanics in computer tasks differ by gender. J Electromyogr Kinesiol. 2009;19(3):428-436. 8. Kryger AI, Andersen JH, Lassen CF, et al. Does computer use pose an occupational hazard for forearm pain; from the NUDATA study. Occup Environ Med. 2003;60(11):e14. doi:10.1136/oem.60.11.e14. 9. Burgess RA, Thompson RT, Rollman GB. The effect of forearm posture on wrist exion in computer workers with chronic upper extremity musculoskeletal disorders. BMC Musculoskelet Disord. 2008;9:47. doi:10.1186/1471-2474-9-47. 10. Povlsen B, Rose RL. Managing type II workrelated upper limb disorders in keyboard and mouse users who remain at work: a case series report. J Hand Ther. 2008;21(1):69-79. 11. Chen HM, Leung CT. The effect on forearm and shoulder muscle activity in using different slanted computer mice. Clin Biomech (Bristol, Avon). 2007;22(5):518-523. 12. Cook C, Burgess-Limerick R, Chang S. The prevalence of neck and upper extremity mus-
culoskeletal symptoms in computer mouse users. Int J Ind Ergon. 2000;26(3):347-356. 13. MacIver H, Smyth G, Bird HA. Occupational disorders: non-specic forearm pain. Best Pract Res Clin Rheumatol. 2007;21(2):349365. 14. Bleecker ML, Celio MA, Barnes SK. A medical-ergonomic program for symptomatic keyboard/mouse users. J Occup Environ Med. 2011;53(5):562-568.
) Around the Globe
iMosaic Integrative Medicine Conference

Minneapolis, MN, April 6 to 10, 2011

By David W. Lescheid, PhD, ND
ne of the premier events in integrative medicine conferences in North America in 2011 was the Integrative Medicine Offering ScienceBased Alternatives in Collaboration (iMosaic) conference held in Minneapolis, Minnesota, from April 6 to 10. For the rst time, 4 different not-forprot national integrative medicine organizations collaborated together to design, develop, and deliver a conference. The participating organizations are an integral part of the integrative medical consortium and included the American Academy of Environmental Medicine, the American College for the Advancement of Medicine, the American Holistic Medicine Association, and the International College of Integrative Medicine. The main target audience was physicians and specialists, but there also were naturopathic physicians, nurse practitioners, chiropractors, and pharmacists in attendance. Approximately 450 to 500 physicians were enrolled in the 3-day conference. Further details can be viewed at the conference Web site (http://www.imosaicconference. com/). The initial 2 days consisted of different workshops for physicians to learn scientic supporting material and practical tips for their practice. There were multiple unique choices available, including The Diagnosis and Treatment of Inhalant Allergies, Advanced Heavy Metal Toxicology for
the Experienced Physician, Chelation Therapy Training Course, Pediatric and Womens Environmental Medicine, The New Endocrinology, and A New Way to Look at Your Practice: Environmental Medicine, Nutrition and Nutritional IV Therapy, and workshops on The Diagnosis and Treatment of Chemical Sensitivities. These workshops, delivered primarily by physicians, provided a good foundation of scientic knowledge for the participants. The main conference was structured with 3 different keynote speakers delivering 1.5- to 1-hour general sessions in the morning and early afternoon and then a series of up to 18 different 1- to 2-hour breakout sessions in the late afternoon and early evening. The overall content of the general sessions was diverse and entitled A 360 Look at Current Topics in Integrative Medicine: Educating Physicians to Provide Patients With New Choices and New Hope. Many of the keynote speakers were exemplary leaders in integrative medicine, including Alan Gaby, MD; Jim Roberts, MD; Tieraona Low Dog, MD; Russell Jaffee, MD; Kenneth Bock, MD; Joseph Brewer, MD; Greg Plotnikoff, MD; Robert Hedaya, MD; and Michael Murray, ND. Overall, the speakers of the general sessions were excellent and the material delivered was cutting edge, practical, and in alignment with current scientic knowledge. Speakers from the numer-
ous breakout sessions delivered information ranging from legal, regulatory, and insurance issues to genetic polymorphisms associated with individual differences in detoxication pathways in the liver. Most of these seminars were well presented, with current scientic knowledge from mainstream medical literature supporting alternative medical approaches. Along with the considerable scientic proof presented, there also were many practical clinical pearls that could immediately be implemented in clinical practice to improve patient outcomes. Bioregulatory Medicine was represented at this conference with a sunset launch party of the American Society of Bioregulatory Medicine that included a short introductory lecture by David Riley, MD. Overall, the level of knowledge transfer from the chosen speakers and the level of interest by the attendees in the iMosaic conference was high, and there was some discussion of planning another collaborative conference similar to this one in 2012. The 2011 iMosaic conference denitely delivered its goal of providing a platform for integrative medical physicians to get together to learn about common issues and provide synergy; if this conference continues, it will soon become one of the premier educational and collaborative events in North America for integrative medical practitioners.|
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) Re f r e s h Yo u r H o m o t ox i c o l o g y
Repetitive Strain Injury as a Model of Inflammation

By Konstantin Cesnulevicius, MD, PhD
Introduction Bioregulatory Medicine is an innovative approach to disease management, including conditions with immunological and inammatory pathophysiological features, such as work-related musculoskeletal disorders or repetitive strain injuries (RSIs).1 Repetitive strain injuries affect muscles, tendons, nerves, and other connective tissues, including lymphatic and blood vessels. They develop over time, and the physical symptoms (eg, pain, discomfort, numbness, and tingling) may linger.2 The effects of RSIs may inuence work, leisure activities, and sleep. Finally, mental health may be affected, including the possibility of major depression. Therefore, it is important to explore all possible treatments to alleviate the potential lasting impact of RSIs. Although treatment of RSIs with conventional medications and even surgery can be successful, the Bioregulatory Medicine approach includes the use of agents with bioregulating properties. Traumeel (Biologische Heilmittel Heel GmbH, Baden-Baden, Germany) is the most well-known such medication for the treatment of RSIs. The benets of its 14 natural ingredients include the following: immunomodulation, modulation of inammation, antioxidant support, regulation of pain responses, healing, protection of mucosa, control of proliferation, and support of tissue remodeling processes. It also has antibacterial, antiviral, antihemorrhagic, and spasmolytic effects.1 Prevalence, Incidence, and Importance of Studying RSIs Previous research has indicated that RSIs may develop from and inuence a broad range of occupations/activities. Articles have focused on ultrasonographers, equestrian athletes, ballet dancers, bicyclists, baseball players, swimmers, triathletes, golfers, bull riders, martial artists, sign language interpreters, skeletally immature patients, college students, heavy computer users, assembly line workers, tailors (seamstresses), surgeons, dentists, and nurses.3 Individuals with RSIs may experience chronic pain and discomfort, along with psychological distress.2,4 In most, if not all, cases, RSIs do not lead to mortality. However, they can lead to signicant morbidity.3 Repetitive strain injuries can affect the following body areas: neck/shoulder, elbow/lower arm, wrist/hand, back, knee/lower leg, and ankle/foot. The specically diagnosed conditions that result from RSIs include carpal tunnel syndrome, cubital tunnel syndrome, tendinitis, tenosynovitis, epicondylitis, rotator cuff tendinitis, ulnar nerve entrapment, and hand-arm vibration syndrome.2,5 According to recent research, the incidence of RSIs may be nearly impossible to estimate.3 However, the annual incidence of upper extremity disorders in the United States has been estimated as between 4.5% and 12.7%.3 A different article indicated that the incidence of RSIs in Canadians was approximately 10%.2 The facJournal of Biomedical Therapy 2011 ) Vol. 5, No. 2
tors that may be involved in the incidence of RSIs include sex and age. Persons aged 40 to 49 years have been implicated as the individuals who are most affected by RSIs. In women, obesity has been related to RSIs. Comorbidities associated with RSIs include arthritis or rheumatism (in both men and women) and thyroid conditions (in women only). Both workplace stress and daily life stress have also been associated with RSIs.2,3 The causes of RSIs include the following: (1) repetitive activity, such that individuals are challenged and do not have sufficient time to recover; (2) malpositioning; (3) lifting; (4) pushing or pulling; and (5) vibration.3,4 Research3 indicates that the most important factor leading to these types of injuries is the repetitive activity, although the specic type of force leads to different outcomes. The causes of RSIs are most often associated with the workplace (>50%); they are secondarily associated with sports or physical exercise (15%20%). Finally, they can be associated with chores/unpaid work/education (15%-20%) and leisure activities/ hobbies (<10%).2 Individuals affected by RSIs tend to have more frequent visits to general practitioners, chiropractors, and physiotherapists.2 Current Pathophysiological Model for RSIs The pathophysiological model for RSIs includes tissue injury, acute inammation, and tissue reorganization
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) Re f r e s h Yo u r H o m o t ox i c o l o g y
as the potential major mechanisms involved.1 In this article, modulation of the acute inammatory part of this pathophysiological model by Traumeel is discussed. There are other products wth bioregulating properties that could potentially be used to treat the other contributing components. Scientic data indicate that Traumeel may be a benecial addition when caring for patients with RSIs. Traumeel modulates inammatory pathways by downregulating proinammatory cytokines and upregulating antiinammatory cytokines, reducing edema, promoting phagocytosis, and improving wound healing.1 Traumeel inuences tissue remodeling by affecting cells that produce extracellular matrix and inhibiting metalloproteinases.1 The specic role of Traumeel for RSIs and other conditions is still being studied. Its potential has not been completely elucidated. Role of Integrative Medicine in Treating RSIs Initially, RSIs may be treated with watchful waiting or conservative therapy, such as rest (ie, avoidance of associated activity), ice on the affected area, and immobilization of the affected area.5 Certain types of exercise may also be benecial. If these conservative treatments are not effective, medications may be administered. The current treatments for RSIs include steroids and nonsteroidal anti-inammatory drugs. However, one potential alternative medication for treating RSIs is Traumeel. Traumeel has bioregulating properties and may be used to successfully treat RSIs. Because of the multicomponent nature of its composition, Traumeel has been shown to have multitargeted action, downregulating potentially damaging components of the inammatory cascade in addition to upregulating components that help to modulate the intensity of the response. Furthermore, Traumeel also has the potential to relieve pain, support physiological tissue remodeling, regulate the vascular response, and act as an antimicrobial agent, if necessary.1 The commonly prescribed conventional medical agents (ie, steroids and nonsteroidal anti-inammatory drugs) are directed toward suppression of proinammatory players.1 In contrast, medications with bioregulating properties, such as Traumeel, are aimed at the modulation of both proinammatory and antiinammatory pathways vs suppression.1 Traumeels natural ingredients act synergistically to modulate inammation. Preclinical research using human cells and cell lines has proven Traumeels anti-inammatory properties.1 Other medications that individuals may take for RSIs include muscle relaxants, opiates, tricyclic antidepressants, and sleep medications.3 Finally, surgery remains an option for the treatment of RSIs. The fact is that RSIs should be addressed as soon as possible to avoid long-term physical and mental symptoms. In addition to conventional and alternative medications, prevention may be a way to help alleviate RSIs. Because RSIs are so often associated with the workplace, employers may benet from implementing preventative techniques.5 These techniques may help decrease the potential lost productivity and increased medical expenses and disability payments associated with RSIs.5 However, to implement prevention, employers must determine the work-related risk factors and make the correct modications.5 Overall, job modications may be advantageous for both employers and employees. Conclusions The continued and expanded use of medications with bioregulating properties has led to improvements in paJournal of Biomedical Therapy 2011 ) Vol. 5, No. 2
tient outcomes. The eld of Bioregulatory Medicine stresses the importance of using complex medications to target multiple components of networks of disease simultaneously and, therefore, increase the ability to provide complete and effective resolution. Furthermore, the use of complex medications in highly diluted concentrations has been shown to be effective and has a high margin of safety in all population groups. These types of medications are widely used in Europe, South and Latin America, and many other parts of the world. They assist with regulating the bodys own immune system so that the body is more likely to heal efficiently and completely. One of the most studied and characterized medications in Bioregulatory Medicine is Traumeel. Traumeel is effective in RSIs specically because of its anti-inammatory effects. For individuals with potentially long-term symptoms, such as those with RSIs, new treatment strategies offer an opportunity for even better results. Further research on medications with bioregulating properties, especially Traumeel, should verify the existing evidence and expand on the potential mechanisms in disorders such as RSIs.|
References 1. Cesnulevicius K. The bioregulatory approach to work-related musculoskeletal disorders: using the multicomponent ultra low-dose medication Traumeel to target the multiple pathophysiological processes of the disease. Altern Ther Health Med. 2011;17 (2 Suppl):S8-S17. 2. Tjepkema M. Repetitive strain injury. Health Rep. 2003;14(4):11-30. 3. Laker SR, Sullivan WJ, Strum S. Overuse injury. eMedicine Web site. http:// emedicine.medscape.com/article/313121overview#a0104. Updated March 12, 2008. Accessed November 3, 2011. 4. Shanahan EM, Jezukaitis P. Work related upper limb disorders. Aust Fam Physician. 2006;35(12):946-950. 5. Rempel DM, Harrison RJ, Barnhart S. Workrelated cumulative trauma disorders of the upper extremity. JAMA. 1992;267(6):838842.
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Clinical Trials: An Overview

By Robbert van Haselen, MSc
In the previous article in this series, an overview of the most important clinical research designs was provided. Given the importance of clinical trials in evidence-based medicine, I will elaborate a bit further on the different types of clinical trials.
linical trials are experiments in
which the efficacy and safety of a treatment are investigated. The term clinical trial is subject to a wide variation of use; the main types will be further claried in this article. Phases of Clinical Trials Four phases of clinical trials are distinguished1: Phase I trial: First testing of substances on healthy volunteers. Phase I trials of conventional medicine primarily focus on obtaining safety and pharmacological data. Therefore, a homeopathic drug proving (also called a homeopathic pathogenetic trial) is similar, but not completely identical, to a phase I trial. Phase II trial: Initial trials to examine efficacy. Usually, subjects are allocated at random to study and control groups. Phase III trial: Larger trials with placebo and/or active treatment control for complete and conrmative assessment of efficacy and safety.
Phase IV trial: Conducted after the regulatory authority has approved registration. In conventional medicine, a common aim is to estimate the occurrence of rare adverse events and other potential effects of actual use in clinical practice as part of postmarketing surveillance. The previously described distinction in phases was primarily developed as a regulatory framework for conventional drug development; therefore, although there are many similarities, this phasing cannot always be transferred on a 1-to-1 basis to research on homeopathic and/or bioregulating medications. Theoretically, all clinical trials on homeopathic medications that are already registered are to be considered phase IV trials; therefore, this would render the previous distinction in phases irrelevant for application in homeopathy. However, in practice, the specic regulatory context for homeopathic medications is ignored and reference is made to these phases.
From a methodological point of view, the term clinical trial does not always imply the presence of a control group. For instance, it is possible to set up a phase II clinical trial without a control group. The key distinguishing feature compared with observational research designs is that, in a clinical trial, the intervention is manipulated (eg, a specific dose of a specic medication in a specic patient population) with a view to assessing efficacy and safety. Pragmatic vs Explanatory Clinical Trial Another useful distinction is that between a pragmatic and an explanatory clinical trial. An explanatory trial is primarily aimed at isolating the effects of an intervention from the other determinants of outcome (assessing efficacy). Therefore, these trials are usually conducted in highly preselected, as homogeneous as possible, patient populations. A pragmatic trial is a study aimed at investigating how an intervention can improve the health status of a specied population, with a view to inform decision making (assessing effectiveness). Therefore, these trials are usually conducted in more heterogeneous patient populations that are representative of those seen in routine clinical practice. Informing decision making can also include the (health) economic perspective.
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Proof-of-Concept vs Conrmatory Trial A further distinction can be made between proof-of-concept and conrmatory trials. Proof-of-concept trials are also more loosely referred to as pilot trials. Their main objective is the generation and selection of the most promising hypotheses to be investigated further in conrmatory trials. Pilot trials are important from the point of view of signal detection and from a practical point of view: conrmatory trials will require many subjects and are expensive. Pilot trials can be a cost-efficient way to increase the likelihood of success in conrmatory trials. However, care should be taken when conducting small pilot trials. The lower the number of subjects, the greater the likelihood that a false-positive signal is generated simply because of chance. There are no xed rules on what is a suitable number of subjects in pilot trials because this will depend on the expected effect size. As a rough guide, any trial with up to 100 subjects will usually be a proofof-concept trial. Conrmatory trials are designed to conrm the presence of an effect on a predened main outcome of interest and are subject to strict predened rules on the statistical assessment; in proofof-concept trials, the primary objective is not always to reach statistical signicance because the effect sizes are not yet known.
Corgarashu/Fotolia.de
Unit of Analysis A lesser-known distinction is that based on the unit of analysis in clinical trials. The most common situation is that individual patients are the unit of analysis. Average effects are then compared between groups (parallel-group clinical trials) or within groups of patients (crossover clinical trials). In cluster-randomized trials, a group of individuals is randomized to receive the same treatment together. An example is when children in some schools are given one vaccine and those in other schools are given another vaccine, and the protection offered is compared. In this case, the unit of analysis is a group (cluster) of individuals (in the previously mentioned example, the school would be the unit of analysis).2 Cluster-randomized trials are less common, and a more detailed discussion is outside the scope of this article. A third option is a socalled N-of-1 trial. This is effectively a controlled trial in a single individual. The most common design is that a single patient receives the study drug or placebo during a study period in which multiple treatment crossovers occur in a randomized and double-blind manner. This design is mainly feasible to assess treatments with short-term effects that wear off quickly (to prevent carryover effects of one treatment period into the next), and this is not often the case in home-
opathy. The main types of categorizations for clinical trials are summarized in the Table. The Appendix includes a glossary of terms commonly used in connection with clinical trials. Further Considerations Given the wide variety in types of clinical trials previously outlined, possibilities and limitations should primarily be considered and discussed per type of clinical trial. This article, therefore, will be limited to a few general comments. Clinical trials are powerful methods for assessing cause-and-effect relationships. Historically speaking, the rst recorded clinical trial was conducted in 1747 by a ships physician, James Lind, MD, who allocated sailors with scurvy into 3 treatment groups and discovered that those who received citrus fruits were cured. After World War II, randomized controlled trials (RCTs) obtained their current dominance in evidencebased medicine. The James Lind library (http://www.jameslindlibrary. org) provides an extensive overview of the historical development of tests of treatments in medical care. This library also contains references to some of the rst proving experiments conducted by homeopathic practitioners in the 19th century. For further reading on the topic of clinical trials, the book by Pocock5 is useful.
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Although the enormous contributions made by clinical trials to medicine are beyond dispute, there are also some evident limitations. A well-known limitation is that clinical trials are not, or are less, suitable to identify less common or rare adverse effects. Randomized trials may also prove to be unnecessary, inappropriate, impossible, or inadequate in several cases.6,7 In general, RCTs have been described as the best way to assess whether an intervention works, but [] arguably the worst way to assess who will benet from it.8 This generally means that they can only be a potentially effective method of measuring treatment effect on a well-dened study group. Any other use is, in fact, an off- or extended-label use. Randomized controlled trials essentially compare average treatment effects across groups, meaning that although some patients will have beneted, others have not responded at all. Therefore, clinical trials, even those with positive results, effectively mask that several individual patients have not responded to therapy. The calculation of a measure such as the number needed to treat (NNT) in placebo-controlled trials can provide some indication of the response rate (a high NNT would suggest a relatively high nonresponse rate); this can even be adapted to individual patients,9 but the application and interpretation of such individualized measures remains relatively complex and is not always feasible. Within the context of an increasingly reductionist conventional medicine in the 20th century, the issue of nonresponse in clinical trials has long been neglected. Only in recent years, because of advances in genomic technologies, systems biology and systems pharmacology are experiencing a revival and have given a major boost to the concept of a more individualized medicine.10 On the other side of the same spectrum, there is a revival of interest in clinical case reporting that is among others reected in the emergence of a cases network and some new journals dedicated to case re porting (http://casereports. bjm.com). Thus, although RCTs are still dominant and systematic reviews of RCTs are at the top of a hierarchy of evidence, there is an increasing movement into the direction of a nonhierarchical research framework, in which clinical trials and other methods contribute substantially to the totality of evidence required for optimum patient-centered medicine. These trends t well with the overall approach in homeopathy and Bioregulatory Medicine; therefore, many opportunities lie ahead in this respect.|
References 1. Porta M, Last JM, eds. A Dictionary of Epidemiology. Oxford, England: Oxford University Press; 2008. 2. Li-Wan-Po A. Dictionary of Evidence Based Medicine. Milton Keynes, England: Radcliffe Medical Press; 1998. 3. Jadad AR, Moore RA, Carroll D, et al. Assessing the quality of reports of randomized clinical trials: is blinding necessary? Control Clin Trials. 1996;17(1):1-12. 4. Schervish MJ. P values: what they are and what they are not. Am Stat. 1996;50(3):203206. 5. Pocock S. Clinical Trials: A Practical Approach. Chichester, England: John Wiley & Sons Ltd; 1983. 6. Black N. Why we need observational studies to evaluate the effectiveness of health care. BMJ. 1996;312(7040):1215-1218. 7. Grootendorst DC, Jager KJ, Zoccali C, Dekker FW. Observational studies are complementary to randomized controlled trials. Nephron Clin Pract. 2010;114(3):c173-c177. 8. Mant D. Can randomized trials inform clinical decisions about individual patients? Lancet. 1999;353(9154):743-746. 9. Cook RJ, Sackett DL. The number needed to treat: a clinically useful measure of treatment effect. BMJ. 1995;310(6977):452-454. 10. van der Greef J, McBurney RN. Innovation: rescuing drug discovery: in vivo systems pathology and systems pharmacology. Nat Rev Drug Discov. 2005;4:961-967.
Table. Overview of Different Types of Categorizations for Clinical Trials
Variable Phase of trial
Category Phase I-IV
Comment This categorization is primarily driven by a conventional regulatory perspective Perspectives range from understanding the specific effects of medications under ideal conditions (efficacy) to the roles of medications in disease management in routine clinical practice (effectiveness) The main perspective is hypothesis generation vs hypothesis confirmation The perspective can range from comparing clusters of individuals to deciding on the optimal treatment for single patients
Outcome focus
Explanatory vs pragmatic
Hypothesis focus
Proof of concept vs confirmatory
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Unit of analysis
Clusters of individuals, individuals, or single patients
Appendix. Glossary of Terms Used in the Context of Clinical Trials Bias: Systematic deviations of results or inferences from the truth. Many subtypes of bias are distinguished, such as selection bias, information bias, and performance bias. In clinical trials, it can be the result of conceptual or methodological aws in study design, data collection, or analysis or interpretation of results. 95% Condence interval: A range of values known to contain the true parameter value with 95% certainty. Crossover trial: This is a clinical trial in which subjects, on completion of treatment A, are switched to treatment B after an appropriate washout period. Half of the subjects are randomly allocated to receive the treatments in the order rst A, then B and the other half in the order rst B, then A. Such trials are only feasible if the washout period is sufficiently long to exclude that effects in the rst treatment period are carried over into the second treatment period. Institutional review board (also called ethical committee): A committee of physicians, statisticians, researchers, community advocates, and others that ensures that a clinical trial is ethical and that the rights of study participants (including animals) are protected. All clinical trials must be approved by an institutional review board before they begin. Intention to treat: Analysis of clinical trial results that includes all data from participants in the groups to which they were randomized, even if they never received the treatment. The opposite is a per-protocol analysis in which only the subjects that completed the study per protocol are included. The consensus is that the exclusion of study subjects from the analysis can lead to bias. Therefore, in general, an analysis by intention to treat, in which values for missing data are statistically imputed, is recommended. Jadad score: This is a score conceived by Jadad et al,3 commonly used to independently assess the quality of a clinical trial. The score is calculated on the basis of an assessment of the following study elements: randomization, blinding, and handling of dropouts. The score ranges from 0 (very poor) to 5 (rigorous). Number needed to treat (NNT): In clinical trials, a variable that expresses the number of persons who need to be treated with the treatment of interest for 1 additional patient to benet compared with control treatment. This parameter can be useful in assisting clinical decision making. For example, in a comparative study, treatment A is compared with treatment B (placebo). Suppose the proportion of patients treated successfully with treatment A is 60% and those treated successfully with placebo is 40%. The difference in success rate is 20% (0.2). The reciprocal of this value, 5 (1/0.2), is the NNT. This is interpreted as follows: on average, 5 patients need to be treated with treatment A for 1 additional patient to be successfully treated than would be the case if they received treatment B. The number needed to harm applies to the risk of adverse events. Suppose in the same trial that 20% of patients who received treatment A experienced a headache, compared with 15% who received treatment B (placebo), indicating a difference of 5% (0.05). This results in a number needed to harm of 20 (1/0.05). In plain language, this means that treating patients with A instead of B would, on average, result in 1 more case of headache per 20 patients. Standard deviation (SD): The most commonly used measure of the spread of a data set, representing the average deviation of the mean of the data set. Statistical signicance: The probability that an event or difference occurred by chance alone. The P value assesses the strength of the evidence against the null hypothesis, which postulates that there is no effect. In general, results with P .05 are not considered strong evidence. The P value needs to be considered with other data from the experiment to provide a more objective measure of the support for the hypothesis.4 In clinical trials, the level of statistical signicance depends on the number of participants studied in conjunction with the magnitude of the differences observed.
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The Role of Vertigoheel as an Adjuvant Treatment in Patients With Transient Ischemic Attacks An Observational Study
By Petr Sedlek, MD, and Stanislav Rika, MD
Introduction The objective of this study was to examine the clinical use of Vertigoheel in the management of patients with a transient ischemic attack (TIA). From our observations, approximately 15% of rescue service clients are patients who have experienced an acute cerebrovascular accident. The most frequent diagnoses encountered by the rescue service in the Czech Republic are cerebrovascular accidents with neurological symptoms, epilepsy, and TIA. Patients with a TIA experience a short period of unconsciousness that is usually resolved by the time the rescue service arrives. Almost all patients complain of vertigo. Multiple other symptoms can occur, such as vision disorders, dysarthria, concentration disorders, nausea, and uncertain gait. Conventional management of patients with TIA consists of etophylline, 160 mg intravenously or 240 mg intramuscularly, and the instruction to stay at home. In approximately 50% of the patients, the rescue service is called back after 2 to 4 hours, with vertigo as the main persistent symptom in most cases. The conventional management of patients with TIA is, therefore, not always fully effective.
The use of homeopathic medications in the treatment of emergency conditions is not common in the Czech Republic. Vertigoheel is well established as a homeopathic medicinal product for the treatment of vertigo.1-5 The group of patients with TIA is of high interest because of the high incidence of persistence of vertigo. We, therefore, investigated if Vertigoheel is useful as an addon treatment in patients with TIA. The results of this study were previously reported at the homeopathic LIGA conference in 2010.6 Materials and Methods This was an observational cohort study with historical controls. The study base consisted of patients with TIA treated with Vertigoheel as an adjuvant treatment by the rescue service in Vlaim, Czech Republic. Patients seen from February 2007 to October 2008 were included. The ingredients of Vertigoheel and their characteristic homeopathic symptoms are given in the Table. In this study, 1 ampoule (1.1 mL) of Vertigoheel injection solution was administered intramuscularly, in a single dose. Conventional standard treatment is ambulant and consists of etophylline, 160 mg intravenously or 240 mg intramuscularly, and
the instruction to stay at home. Data before the adjuvant use of Vertigoheel demonstrated that, in approximately 50% of patients, the rescue service in Vlaim would be called back after 2 to 4 hours. Vertigo was the main persistent symptom reported by most of these patients. Results A total of 64 patients (age range, 55-89 years) were included. Four patients (6%) called back after 2 to 4 hours with vertigo: 2 of them developed acute cerebrovascular accidents with neurological symptoms and 2 experienced recurrences of TIA, with short-term unconsciousness. Compared with historical data before the introduction of Vertigoheel, this amounts to a reduction of almost 90% in the call-back incidence. Discussion The results of this study suggest that adjuvant Vertigoheel treatment can substantially reduce the incidence of persistent vertigo in patients with a TIA. Surprisingly, nausea also often disappeared. A limitation of this study is that the study population was relatively small. Also, the use of historical, rather than placebo, con-
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Table. Ingredients of Vertigoheel: Potency, Amount, and Main Homeopathic Indications
Ingredient Potency/Amount in 1.1 mL of Injection Solution D3/7.7 L Main Homeopathic Indications
Anamirta cocculus (Indian cockle)
Feeling of dizziness as the result of various causes, associated with nausea and severe fatigue; motion sickness, especially in the car or train, or sea sickness; hardening of the arteries in the brain; cerebral sclerosis; neurological disorders; and moodiness, including sleeplessness because of overwork, staying up late, and/or emotional worries. Hardening of the arteries in the brain; cerebral sclerosis; moodiness; dizziness triggered by head rotation, on standing, and/or when lying down; rotational dizziness; light intolerance; and generalized functional, physical, and mental sluggishness. Nerve hypersensitivity and nervous exhaustion, autonomic nervous system imbalance, moodiness and sadness, calcication of blood vessels, aging, insomnia due to worries and fears, and nervousness. Inammation of the gastrointestinal tract, dizziness, sensitivity to cold, nervousness, and motion sickness improved by closing the eyes.
Conium maculatum (hemlock)
D2/1.1 L
Ambra grisea (ambergris)
D5/1.1 L
Petroleum recticatum (rock oil)
D7/1.1 L
trol data implies that the results should be interpreted with caution. However, Vertigoheel was a suitable supplement to the therapy in the study population. Vertigoheel is a medication for dizziness; it stimulates the central nervous system. It can be demonstrated by neuro-otological examination that Vertigoheel activates the statoacoustic regulation systems in the infratentorial area of the brain stem. Treatment with Vertigoheel decreases vertigo and nausea, reduces lightheadedness and postural instability, and improves central vestibulo-ocular nystagmus reactions. Electroencephalographic computer audiometry has revealed increased activity of the pathways from the acoustic nerve to the inferior colliculus of the corpora quadrigemina.7,8 Other treatment combinations, which are able to inhibit or suppress the described symptoms, can be used to treat TIA with manifestations of the previously mentioned symptoms in patients receiving home care. Partial success has been reported for the etophylline plus thiethylperazine (Torecan) combination.9 Additional volume replace-
ment with crystalloids is sometimes successful, especially in elderly patients, in whom hypovolemia due to simple dehydration is one of the most frequent causes of TIA. It would be interesting to initiate a randomized, comparative, 3-armed trial evaluating the efficacy of the following treatments: etophylline + Vertigoheel etophylline + thiethylperazine etophylline + 500 to 1000 mL of crystalloids An additional important study would be to conduct a randomized controlled trial comparing standard treatment plus Vertigoheel with stan dard treatment plus a suitable placebo. A special focus should be the treatment of the most perturbing symptoms, such as vertigo and nausea. Despite the absence of conrmatory data, this study clearly suggests that Vertigoheel has benecial effects in the treatment of patients with TIA. |
References 1. Weiser M, Strsser W, Klein P. Homeopathic vs conventional treatment of vertigo: a randomized double-blind controlled clinical study. Arch Otolaryngol Head Neck Surg. 1998;124(8):879-885.
2. Issing W, Klein P, Weiser M. The homeopathic preparation Vertigoheel versus Ginkgo biloba in the treatment of vertigo in an elderly population: a double-blinded randomized, controlled clinical trial. J Altern Complement Med. 2005;11(1):155-160. 3. Weiser M, Strsser W. Behandlung des Schwindels: Vergleichsstudie Homopathikum vs Betahistin. Der Allgemeinarzt. 2000;22(13):692-694. 4. Wolschner U, Strsser W, Weiser M, Klein P. Behandlung des Schwindels mit einem modernen Homopathikum: Ergebnisse einer referenzkontrollierten Kohortenstudie. Biol Med. 2001;30(4):184-190. 5. Schneider B, Klein P, Weiser M. Treatment of vertigo with a homeopathic complex remedy compared with usual treatments: a meta-analysis of clinical trials. Arzneimittelforschung. 2005;55(1):23-29. 6. Rika S, Sedlek P. Report on the use of the homeopathic remedy Vertigoheel in eld practice of the rescue service. Poster presented at: 65th World Homeopathic Congress of Liga Medicorum Homoeopathica Internationalis; May 18-22, 2010; Redondo Beach, CA. 7. Claussen CF. Die Behandlung des Syndroms des verlangsamten Hirnstammes mit Vertigoheel. Biol Med. 1985;14(3):447-470, and 1985;14(4):510-514. 8. Claussen CF, Bergmann J, Bertora G, Claussen E. Clinical experimental test and equilibrimetric measurements of the therapeutic action of a homeopathic drug consisting of ambra, Cocculus, Conium and mineral oil in the diagnosis of vertigo and nausea [in German]. Arzneimittelforschung. 1984;34(12):1791-1798. 9. Macek Z, et al. Neurologie in der arztlichen Praxis. Mnchen, Germany: Urban & Schwarzenberg; 1970.
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) Meet the Expert
Dr. Jan Kersschot

By Bruno Van Brandt
r. Jan Kersschot was born on August 15, 1960, in Reet, close to Antwerp, Belgium. He studied medicine at the University of Antwerp and graduated in 1986. In 1988, he married Christine, with whom he has 2 daughters, now aged 17 and 20 years. When Jan was still a student, his father, a general practitioner, had patients who traveled from Belgium to Germany to be treated with neural therapy, an unknown method of injection therapy in Belgium at that time. On his fathers request, Jan participated in a course on neural therapy in Freudenstadt, Germany, in September 1984. Jan believed that this was an interesting modality that could be useful in medicine. He was also surprised that he had not heard about it in his medical training at the university. As soon as Jan had completed his studies, he started his own practice and extensively used the injection therapy techniques whenever they were well indicated.
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Within this bioregulatory environment of neural therapy in Germany, Jan quickly discovered that, in addition to procaine, there were other biotherapeutic medications available as injectable ampoules. Although he discovered a few companies that provided these medications, the pivotal point came at a medical congress in Baden-Baden, Germany, when he met a representative of Heel who claimed interesting results with injectable biotherapeutic agents. He gave Jan some samples of Traumeel ampoules and asked him to report on his experience. Jan was surprised to observe that his patients had better and longer-lasting results when he added these ampoules to the procaine or lidocaine injections that he routinely administered. When he noticed the benets of Traumeel in his practice over and over again, his condence in this type of medication grew, and he started injecting other products, such as Zeel and Discus compositum. Over time, he used more and more biotherapeutic medications and fewer local anesthetics. Jans treatment approach became even more integrative when he studied mesotherapy and trigger-point therapy. He began to combine his already standardized biotherapeutic injections with insights from mesotherapy, trigger-point therapy, and prolotherapy and developed new techniques and strategies.
In 1991, Jan gave a lecture at a medical congress in Ostend, Belgium. For the rst time, he introduced his integrative method as Biopuncture and a new injection method was born. Jan chose the term Biopuncture because it described the technique: local injections in specic locations with safe and effective biotherapeutic medications. During the past 20 years, the method of Biopuncture has evolved, and it is still evolving now. Recently, the technique has been standardized by a team of experts, resulting in a new book, The Clinical Guide to Biopuncture, that describes the method in-depth. Since the beginning of Biopuncture some 20 years ago, Jan Kersschot has traveled the world to teach his therapy approach. In the meantime, physicians have been trained, in collaboration with the International Academy for Homotoxicology, to become certied international spea kers on Biopuncture. These speakers help answer the growing demand for Biopuncture training worldwide, although Jan still does a large part of lecturing himself. In his spare time, Jan likes swimming, hiking in nature, cycling, and traveling (his favorite countries are India and Egypt). He is also interested in modern art, photography, and architecture and likes visiting museums while traveling (eg, Museum of Modern Art, Metropolitan, and Tate Modern). Like most Belgians, he enjoys ne cuisine. In particular, red wine and dark chocolate contribute to his joy in life.|

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d 2.00 US $ 2.00 CAN $ 3.

Volume 5, Number 2 ) 2011

Integrating Homeopathy and Conventional Medicine

Pathologies Associated With the Workplace . . . . . . . . . . . . . . 4

Around the Globe

iMosaic Integrative Medicine Conference . . . . . . . . . . . . . . . . 23

Repetitive Strain Injury as a Model of Inammation . . . . . . 24

Meet the Expert

Dr. Jan Kersschot . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

Cover iStockphoto.com/Steve Cole

How Work Affects Our Health

Dr. Alta A. Smit

Journal of Biomedical Therapy 2011 ) Vol. 5, No. 2

Pathologies Associated With the Workplace

* WRMSDs are also designated in the literature as WMSDs.

Working environments and workimpact on peoples health.

related activities can have a signicant

Table 1: Risk Factors Contributing to Work-Related Disorders

Exposure to chemicals, dusts, fumes, smoke, or gas

Journal of Biomedical Therapy 2011 ) Vol. 5, No. 2

Table 2. Types of Work-Related Musculoskeletal Conditions According to Body Region

Lower Limb Nonspe c i f i c Wo r k-Rel ated

Journal of Biomedical Therapy 2011 ) Vol. 5, No. 2

Data from HSE (Health and Safety Executive).6

Journal of Biomedical Therapy 2011 ) Vol. 5, No. 2

Physical stressors (eg, repetitive

Journal of Biomedical Therapy 2011 ) Vol. 5, No. 2

Table 4. Pharmacological Therapies Used in the Treatment of Musculoskeletal Disordersa

Nonsteroidal anti-inammatory drugs Muscle relaxants

Abbreviation: COX, cyclooxigenase. a Data from Laker et al.59

Journal of Biomedical Therapy 2011 ) Vol. 5, No. 2

Journal of Biomedical Therapy 2011 ) Vol. 5, No. 2

Journal of Biomedical Therapy 2011 ) Vol. 5, No. 2

) What Else is New?

Blue-enriched white light in the

ness, performance, and concentration.

the risk of both musculoskeletal disorders and psychovegetative

Working longer hours increases

Office Lighting Affects Productivity

Graveyard Shift Leads to Increased Injuries

Working Overtime Associated With Health Complaints

Scand J Work Environ Health. 2011;37(1):54-61.

Journal of Biomedical Therapy 2011 ) Vol. 5, No. 2

) What Else is New?

Possible adverse effects of headaches, dry eye, and

Noise Exposure Affects Cardiovascular Health

Toner Dust Causes Abdominal Symptoms

Visual Problems Linked to Computer Use

Journal of Biomedical Therapy 2011 ) Vol. 5, No. 2

Work-Related Psychological Stress and the Hypothalamic-PituitaryAdrenal Axis

Table. Bioregulatory Management of Work-Related Stress

Tonsilla compositumd Cerebrum compositum Coenzyme compositum Ubichinon compositum

Journal of Biomedical Therapy 2011 ) Vol. 5, No. 2

Journal of Biomedical Therapy 2011 ) Vol. 5, No. 2

Journal of Biomedical Therapy 2011 ) Vol. 5, No. 2

Bioregulatory Management of Mouse Arm

Cimicifuga-Homaccord (resistant to well-indicated therapy) Spascupreel (for muscle spasms)

Journal of Biomedical Therapy 2011 ) Vol. 5, No. 2

Journal of Biomedical Therapy 2011 ) Vol. 5, No. 2

) Around the Globe

iMosaic Integrative Medicine Conference

Minneapolis, MN, April 6 to 10, 2011

Journal of Biomedical Therapy 2011 ) Vol. 5, No. 2