Gastrointestinal Reflex Presentation

The digestive system functions via a system of long reflexes, short reflexes, and extrinsic reflexes from gastrointestinal (GI) peptides that work together.

Gastro Intestinal Reflexes Slide presentation text

1. Addis Ababa University College of Health Sciences Department of Medical Physiology Presentation on Gastro intestinal ReflexesBy Girmay fitiwi 10/30/2011 1

2. Presentation out Line1.Objectives2.Introduction3.Short reflexes4. Long reflexes 4.1. Defecation reflexes 4.2. Vomition (emesis ) reflexes5. References10/30/2011 gastro intestinal reflexes 2

3. 1. ObjectivesAt the end of this presentation students willable to :-• Mention the types of gastro intestinal reflexes• Clarify the roles of different GI reflexes• Explain the mechanisms of defecation reflexes• list the control mechanisms of defecation• Discuss the mechanism, merits and demerits of vomiting reflexes.10/30/2011 gastro intestinal reflexes 3

4. 2. introduction• The digestive system has a complex system of motility and secretion regulation which is vital for proper function.• Accomplished via a system of long reflexes from the CNS, short reflexes from ENS and reflexes from GI peptides working in harmony with each other.• Three types of gastrointestinal reflexes .10/30/2011 gastro intestinal reflexes 4

5. cont’d1. Local reflexes• Reflexes that are integrated entirely within the gut wall enteric nervous system.• These include reflexes that control much gastrointestinal secretion, peristalsis, mixing contractions, local inhibitory effects.10/30/2011 gastro intestinal reflexes 5

6. GI reflexes cont’d2. Short reflexes• Reflexes from the gut to the prevertebral sympathetic ganglia and then back to the gastrointestinal tract.• These reflexes transmit signals long distances to other areas of the gastrointestinal tract.• gastrocolic reflex• enterogastric reflex.• colonoileal reflex.• Ileogastric reflex10/30/2011 gastro intestinal reflexes

7. GI reflexes cont’d …………3.Long reflexes• Reflexes from the gut to the spinal cord or brain stem and then back to the gastrointestinal tract. Vago vagal reflexes Pain reflexes that cause general inhibition of the entire gastrointestinal tract. Defecation reflexes Vomition reflexes10/30/2011 gastro intestinal reflexes

8. Different nervous reflexes of the GIT10/30/2011 Fig.1 different gastro intestinal reflexes

9. GI reflex cont’d10/30/2011 Fig.2 reflex control of gut activity

10. Distension of stomach by food Mucous membrane of stomach is stimulated Afferents go to internal plexus Efferents from internal plexus G- cells in pyloric Gastric glands glands Release of gastric juice 10Fig .3 Short reflex

11. Presence of food in stomach Mucous membrane of stomach is stimulated Afferents go via the vagus Medullary centre Efferents come via vagus Synapse in the intrinsic plexuses G-cells in pyloric Gastric glands glandsFig.4 Long reflex 11 Release of gastric juice

12. 3.Short Reflexes1. Gastrocolic (Gastroileal) Reflex• Stomach activity leads to ileocecal relaxation and increased mass movements in the colon.• These reflexes are mediated through both long and short nervous pathways (extrinsic and intrinsic) and hormones (CCK, gastrin)  Most evident after first meal of the day.  Often followed by urge to defecate.  New born children routinely defecate after meal.10/30/2011 gastro intestinal reflexes

13. Short reflexes cont’d2.Enterogastric reflex When fat or protein chyme reaches the duodenum, receptors detect and send impulses to enteric nerves of the stomach that in turn cause the inhibition of stomacheal motility and secretion. Delays emptying.3. Intestino-intestinal Distention of one portion of the intestine leads to decreased contractions caudad of the bolus.  Depends on extrinsic neural connections.10/30/2011 gastro intestinal reflexes

14. Copyright © The McGraw-Hill Companies, Inc. Permission required for reproduction or display. 4 Nerve impulses inhibit peristalsis in stomach wall From CNS Vagus nerve To CNS 1 Duodenum fills with chyme 3 Sensory nerve impulses travel to central 2 Sensory stretch nervous system receptors are10/30/2011 Fig.5 enterogastric reflexes 14 stimulated

15. Short reflexes cont’d4. Vago vagal reflexes• GI reflex circuits where afferent and efferent fibers of the vagus nerve coordinate responses to gut stimuli via the dorsal vagal complex in the brain.• Controls contraction of the GI muscle layers in response to distension of the tract by food.• Allows for the accommodation of large amounts of food in the GITs.10/30/2011 gastro intestinal reflexes 15

16. ……….cont’d• Carries signals from stretch receptors, osmoreceptors, and chemoreceptors to dorsal vagal complex where the signal may be further transmitted to autonomic centers in the medulla.• Efferent fibers of the vagus then carry signals to the gastrointestinal tract up to the splenic flexure.10/30/2011 gastro intestinal reflexes

17. ………….cont’dFunction• Active during the receptive relaxation of the stomach in response to swallowing of food .• When food enters the stomach a “vagovagal” reflex goes from the stomach to the brain, and then back again to the stomach causing a reduction in the muscular tone of the stomach wall.10/30/2011 gastro intestinal reflexes 17

18. …………..cont’dMechanism• when the corpus and fundus of the stomach are distended secondary to the entry of a food bolus.• stimulation of the mechanical receptors located in the gastric mucosa stimulates the vagus afferents.• The completion of the reflex circuit by vagus efferents leads to the stimulation of postganglionic muscarinic nerves.• These nerves release Ach to stimulate two end effects.10/30/2011 gastro intestinal reflexes

19. ……………..cont’d1.The parietal cells in the body of the stomach are stimulated to release H+.2. The ECL cells of the lamina propria of the body of the stomach are stimulated to release histamine.10/30/2011 gastro intestinal reflexes

20. 4. Long reflexes4.1 defecation reflexes• An Intrinsic reflex mediated by the local enteric nervous system in the rectal wall.• To be effective it usually must be fortified by parasympathetic defecation reflex• Distention of the rectum causes the internal anal sphincter to relax, which produces the urge to defecate.• The external anal sphincter is under voluntary control.• relaxation of this sphincter, coupled with contraction of the rectum and sigmoid colon, results in defecation.10/30/2011 gastro intestinal reflexes

21. Defecation reflexes cont’d10/30/2011 Fig 6. anatomical view of rectum and anal channel

22. …………..cont’d• Rectum usually (almost) empty (retrograde contractions return content to sigmoideum, until there is too much of it)• Just before defecation mass movement in sigmoideum fills rectum pressure reflex relaxation of inner sphincter (smooth muscle) & contraction of outer sph. (skeletal muscle controlled intentionally via pudendal nerves)• Stretch receptors in rectal wall can adapt – urge to defecate can temporarily subsided suppressed.10/30/2011 gastro intestinal reflexes

23. Defecation Reflexes cont’dA. Intrinsic reflex• Intrinsic reflex mediated entirely by ENS is initiated when feces enters rectum via mass movements and the rectal pressure increase to 55 mmHg. – Peristaltic waves in descending colon, sigmoid and rectum – Relaxation of internal anal sphincter (inhibitory action of the myenteric plexus) – Weak when functioning alone.10/30/2011 gastro intestinal reflexes

24. 10/30/2011 24 Fig7. defecation reflexes

25. …………cont’d B.Parasympathetic defecation reflex • Involves sacral segments of the spinal cord . • Greatly intensifies intrinsic reflex (but is not different qualitatively) • Afferent signals go to sacral cord and then back to descending and sigmoid colon, and rectum by way of parasympathetic fibers in pelvic nerves. • The lower neurons S2-S4 provide sensory and motor fibers for defecation reflex.10/30/2011 gastro intestinal reflexes 25
26. 10/30/2011 gastro intestinal reflexes

27. ………………….cont’d • Afferent signals entering spinal cord initiate other effects that require intact spinal cord.  Deep breath, closure of glottis, and increased abdominal pressure  Relaxation and movement of pelvis floor downward  All work to move fecal contents downward • Spinal transection or injury can make defecation a difficult process. • Cord defecation reflex can be excited (either digitally or with enema) ,Forcing fecal particles into the rectum to cause new reflexes, Not as effective as the natural reflexes.10/30/2011 gastro intestinal reflexes

28. Vomiting (emesis)• The ejection of stomach contents through the mouth.• preceded with nausea, sometimes anorexia, autonomic reactions (salivation, sweating, cold skin,…)• Vomiting center in medulla (next to cardiovascular & respiratory centers).• CTZ located in the root of 4 th ventricle.• Protective reflex against toxicity; however, longer vomiting can cause metabolic alkalosis & dehydration.10/30/2011 gastro intestinal reflexes

29. …………….cont’d  There is a neural connection between vomition center and CTZ.  CTZ causes central vomition and is stimulated by chemical substances (e.g., drugs like morphines , pregnancy, alcohol, movement etc.)10/30/2011 gastro intestinal reflexes

30. Vomiting cont’d• Reverse peristalsis from the middle of small intestine to larynx .• Strong contraction of abdominal muscles&diaphragm.• Relaxation, then closure of pylorus, relaxation of LES and finally UES (glottis closure, inhibition of breathing)• Forced inspiration against closed glottis – intrathoracic pressure, abdominal (diaphragm)10/30/2011 gastro intestinal reflexes

31. …………cont’d• Vomiting may be induced by:-1.Drugs like apomorphine stimulate CTZ.2.Afferent impulses from vestibular nuclei• They mediate vomiting of motion sickness3.Afferent impulses from viscera stimulate vomiting center via NTS.• Vomiting induced in visceral disease.10/30/2011 gastro intestinal reflexes

32. 10/30/2011 gastro intestinal reflexes

33. References• Berne and levy physiology, sixth edition Bruce M.Koeppen, Bruce A. Stanton• Guyton and Hall Textbook of Medical Physiology, 12th Edition.• Human physiology: The Basis of Medicine, 3rd Edition.• Lecture note• Institutional websites10/30/2011 gastro intestinal reflexes 33

 

U.S. and UAE face common healthcare challenges

The U.S. healthcare system and its hospitals are one of the most advanced in the world, despite the current tumultuous changes taking place in the sector. In 2014, 48 per cent of U.S. healthcare spending came from private funds, with 28 per cent coming from households and 20 per cent coming from private businesses, according to a finding by the
Department for Professional Employees (DPE).

It is a well-known fact that American university-affiliated hospitals are in the lead when it comes to research and development. From developing important medications to life-saving procedures, the whole world has benefitted from American innovations. The U.S. government is known to offer grants, patents, and exclusivity to companies who are willing to develop drugs for uncommon diseases.

But the system has certain issues to tackle and one of the common challenges that both the U.S. and the UAE face when it comes to healthcare is fighting obesity. It a growing problem across the world, and a recent study found that more than two billion adults and children across the globe are overweight or obese and suffer severe health problems, with the U.S. leading in such cases.

Reportedly, combining children and adults, the U.S. showed the largest obesity increase, from an obesity rate of 26.5 per cent in 2015. Some of the common risks associated with obesity include cardiovascular disease, diabetes, and cancer, among other life-threatening conditions.

Another study published in the journal Preventive Medicine, found that lack of exercise is contributing to the growing obesity epidemic, and the report found that activity levels of teenagers are shockingly comparable to that of 60-year-olds!

In the UAE too, over 36 per cent of children in the UAE are obese, according to World Health Organisation (WHO). Furthermore, according to a study by University of Washington’s Institute for Health Metrics and Evaluation, 66 per cent of men and 60 per cent of women in the UAE are obese, which clearly indicates that obesity is a advanced disease in the country and if not tackled early on, people are most likely to suffer debilitating health complications.

Dr. James Levine, M.D., Ph.D., Professor of Medicine at Mayo Clinic in Arizona, U.S., told Khaleej Times: “In the UAE, one in five people has type II diabetes. This is because obesity has swept through the adult population, and now children. The startling high rate of obesity-related type II diabetes has implications for the health of the nation, because it is associated with cardiovascular disease and cancer. Of even greater concern, however, is the fact that the rates of diabetes and high blood pressure are not levelling off in the UAE; the crisis is growing. The health consequences associated with diabetes, high blood pressure, cardiovascular disease and obesity are likely to continue to grow unless urgent action is taken. The UAE and the U.S. are on similar trajectories in this regard.”

Top tips to get fit

Dr. James Levine, Professor of Medicine at Mayo Clinic, highlights actions to prevent obesity:

– Be thoughtful about what you eat.

– Avoid second portions, decrease the amount of fat you eat, have scheduled meals and avoid snacks and sugary drinks.

– It is important to sit less and be more active. You don’t need to join a gym (unless you want to). Instead, make sure you walk every hour. Replace sitting times (such as watching TV) with walks and active socialising. Take a walk with a family member or friend, and ensure you take a 15-minute stroll after every meal.

Setting healthcare standards in the UAE

American Hospital Dubai: The hospital is a premium, multi-speciality healthcare facility offering the most advanced treatments for various types of cancers as well as other ailments. It has become the first accredited hospital of Mayo Clinic Care Network in the Middle East.

Cleveland Clinic Abu Dhabi: A branch of the U.S.-based healthcare institution, it offers a model of care, designed to address a range of complex and critical care requirements. It provides patients in the region direct access to some of the world’s best healthcare providers.

 

The Benefits Of Group Physiotherapy

When Linda Veres, Ross Winter and Robert Morassutti happened to sign up for the same physiotherapy class, little did they know the difference group therapy would make.

In fact, studies show that patients who participate in group-based physiotherapy after joint replacement surgery achieve statistically and clinically important improvements in mobility and function, and with similar satisfaction levels as patients who receive one-on-one therapy at home.

“In that group setting, they connected through their experiences of getting through surgery, and a common goal to get moving well again,” says Suzanne Denis, advanced practice physiotherapist, Holland Musculoskeletal Program who remembers Linda, Ross and Robert called themselves ‘the knee people’. They had knee replacement surgery at Sunnybrook’s Holland Centre then returned to join one of the group physiotherapy classes led by physiotherapist Mark Anunciacion.

Even though classes have ended, Linda, Ross and Robert continue to exercise together twice a week, motivating and supporting each other.

Beyond the clinical evidence, here are their reasons why getting together to exercise works:

Camaraderie – social + exercise: Ross says, “Doing physio alongside Linda and Robert who had a similar post-op (post-surgery) sensibility, allowed us to share with each other, experiences, knowledge, advice.”

Context – motivate yourself, but know your limits! “Doing therapy with others helps give you context. Everyone is different, even though we all had the same surgery,” says Robert. “And in some ways, it helped to ‘normalize’ things. We would ask each other: are you still using your cane? Being together gave you permission to either still be using the cane. Or not.”

Commitment: “Sometimes, I’d be thinking to myself: I’d rather not do this [the exercises],” says Robert, “but as a group, we had made a commitment. To be there for each other.” “And keep ourselves motivated,” adds Linda.

Commiserate, but with consideration: “Misery loves company and it’s better to share the pain than to suffer alone,” says Ross. “Group physio gave everyone the occasion to express frustration about their lack of progress, or the discomfort. But temper those occasional complaints, with humour,” says Linda. She recalls the generosity of the volunteers who would get ice for class participants. One particular day, she was feeling quite low and as the volunteer arrived with the ice, she joked, “Do you have gin with that?”

And because knee replacement is a ‘big deal’ even if some say it isn’t, Linda, Ross and Robert also offer words of encouragement:

Connect with friends and family: “As you prepare for surgery, think about what you will need, after surgery. It’s hard to ask for help, but do! And ask for specific help!” “Until you know the ‘new’ you, you need someone there, to help you.”
Careful: “Pace yourself, for yourself, and DO NOT fall!”
Consistency: “You have to keep at it [exercise]! Keep moving! Stretching and strengthening.”
Continuum: “Keep up the momentum even after ‘formal’ physio.”
Celebrate! “Everyone has their markers — milestones of progress, success, recovery.” “Celebrate being closer to what you used to do – getting on a streetcar, being able to put the rugs down again at home, driving a car, taking the bus to go to a movie with a friend…”

 

Physiotherapy and nutrition science courses offer a promising future

Considered one of the oldest ways to cure various physical ailments, the history of physiotherapy can be traced back to ancient Greece. Over the centuries, it has evolved from a simple massage-based treatment to a complex assortment of therapies with multiple and specialized applications.

Physiotherapy

Choosing a career in physiotherapy is a prudent decision in this day and age; it’s a stream that offers numerous job options, including some that are financially as rewarding as being doctors and engineers. Considered an allied health service, physiotherapy comes with a vast range of career alternatives both in India and abroad. At Manav Rachna Educational Institutions, the following courses in physiotherapy are on offer:

Bachelor of Physiotherapy (B.P.T) – A regular full-time course (41/2 years) divided into eight semesters and a six-month internship.

Master of Physiotherapy (M.P.T) – A 2-year course with specializations in musculoskeletal, sports, neurology, and cardiopulmonary physiotherapy

Nutrition and Dietetics

Nutritionists help us understand how diet affects one’s health and well-being. To be a nutritionist, it is necessary to gain a degree in nutrition science or dietetics, which incorporates human physiology and biochemistry. Based on their qualifications, people may find work as nutrition scientists, public health nutritionists, clinical nutritionists, or sports nutritionists. This field focuses on the scientific understanding of nutrition and its practical application in the field of healthcare and patient rehabilitation.

As health centres, fitness centres, and spas continue to flood the market, the career prospects in the field appear increasingly positive. At Manav Rachna, programmes offered under Nutrition & Dietetics include:

B.Sc. Nutrition & Dietetics(3-years) with two months of clinical/ industrial training

M.Sc. Nutrition & Dietetics (2-years) with specializations in Clinical Nutrition and Dietetics, Food Science and Technology, Sports Nutrition, and Public Health Nutrition

PhD in Health Sciences

Is it the right career for you?

As any career counsellor would suggest, it is important to pick a field that suits and matches one’s flair, and this holds true for physiotherapy as well as nutrition and dietetics. From a financial perspective, a career in these fields is definitely a good option, despite both physiotherapy and nutrition being fairly challenging positions. Professionals in these areas are qualified to perform physical examinations and conduct assessments during diagnosis. A successful physiotherapist uses various intervention techniques to treat a patient in the best possible manner.

Nutritionists have ample job prospects in hospitals, nursing homes, residential homes, and private practices. (Manav Rachna)
Job prospects

Due to our sedentary lifestyles, people face frequent musculoskeletal problems, which include issues such as backache, stiff shoulders and neck, osteoarthritis, obesity, etc. In curing such disorders, physiotherapists and nutritionists work wonderfully alongside mainstream doctors. Thus, physical therapists and dieticians/ nutritionists have ample job prospects in hospitals, nursing homes, residential homes, rehabilitation centres, and private practices or clinics. Additionally, qualified professionals can work at out-patient clinics, community healthcare centres, fitness centres or health clubs, occupational health centres, special schools and senior citizen centres.

Job prospects for such graduates are also bright in areas such as teaching and working in foreign countries with companies and NGOs, etc.

Why choose Manav Rachna?

Across a journey of 20 years, 45,000 + students, including an alumni base exceeding 17,000 students have been seen walking the MREI corridors of knowledge. The NAAC accredited ‘A’ Grade institute is committed towards providing quality education by motivating students through highly innovative and flexible horizons. The faculty in physiotherapy and nutrition offers state-of-the-art OPD and nutritional counselling facilities. It also keeps organizing regular workshops to update the knowledge of staffs and students. The centre focuses on evidence-based practice which is carried out in well-equipped labs designed for research purposes. Complete holistic development of students is offered through Personality Development Programs and interdisciplinary learning. International exposure is assured through various conferences and seminars, including international/ national CMEs, seminars, workshops and health camps.

In addition, the institution nurtures active tie-ups with renowned hospitals like VIMHANS, Batra Hospital and Medical Research Center, IBS hospital, ASIAN hospital, Sarvodaya Hospital, Metro Hospital, along with several old age homes and handicap schools.

Globalizing education with international collaborations

In its quest for excellence, MREI have academic tie-ups with 44 foreign universities, across USA, Canada, UK, South America, Far East, and other Asian countries. Partners include AIS St. Helens, Universiti Sains Malaysia, Lahti University, Missouri State University, Purdue University Northwest, and a host of others. The areas of collaborations cover exchange of undergraduate and graduate students, faculty and staff members, joint research and consultancy activities, participation in seminars and academic meetings, exchange of academic materials and other information, special short-term academic programmes and projects, cooperation in curriculum development, collaboration in international seminars and conferences, and cooperation in quality assurance which can transform graduates into quintessential global professionals.

Finally, besides quality education, Manav Rachna also provides 100% on-campus placement assistance to students. Alumni from these courses have been placed with renowned brands such as AIIMS, Batra Hospital, Bharti Enterprises, Apollo Hospital, Qi Spine, Religare, United Health Group, Kareer Gateway, Jindal Industries, Genpact, VLCC, Nutrilife and other leading government and private institutions.

 

Nitrate Rich Foods For Nitric Oxide Production

Nitric Oxide benefits are proven (check out our full spiel here). While you can get access to nitric oxide supplements, its a smart idea to incorporate foods into your regular diet routine that are high in nitrates and promote continuous nitric oxide production in the body. Start with these 18 nitrate rich foods:

18. Dark Cocoa

Several studies have documented that cocoa, especially the raw kind, increases nitric oxide production and lowers blood pressure. There is also evidence of cacao healing the endolethium (the thin layer of cells that lines the interior surface of blood vessels) by increasing the amount of cells that repair it. The crucial part in choosing right kind of cacao is the quality. If possible you should always buy raw unprocessed kind, because the ones they sell on markets are so over-processed that they shouldn’t be even called chocolate anymore.

17. Watermelon

Watermelon contains a lot of the amino acid L-Citrulline that is one of the best natural compounds to increase nitric oxide, proven by countless of studies. Read this post to learn more about L-Citrulline and how it converts into nitric oxide in the body.

16. Pomegranate

If I would have to choose the best food for nitric oxide production and testosterone levels, it would be pomegranate. Pomegranate has been performing perfectly in every single study that it has been researched for, producing effects such as reducing arterial plaque thickness by 30% and increasing testosterone levels by 22% in peer reviewed studies.

15. Walnuts

Walnuts are packed with vitamin E, which helps you arteries and testosterone levels. Also it has been recently studied and proved to increase nitric oxide production and also to lower blood pressure, significantly. This is probably due to the high amounts of L-Arginine found in walnuts, which has been linked to an increase in nitric oxide production, more about L-Arginine here.

14. Spinach

Spinach is known to have one of the highest nitrate contents of all plants, which means that it’s a pretty awesome food to eat if you are looking to increase nitric oxide production. Learn more about nitrates in foods and how those convert into nitric oxide, here.

13. Oranges

Oranges and orange juice contains high amounts of vitamin C, which has been shown to protect your precious nitric oxide molecules from free radicals. So ideally there would be no point in increasing your nitric oxide levels without consuming vitamin C and antioxidants at the same time, because without the vitamin C, your beloved nitric oxide would just oxidize away before really doing anything in your body.

12. Beets

Beetroot is one of those foods that contain nitrates as explained here. The thing that really makes beets so amazing is the fact that it is one of those foods that has highest nitrate count in all of plants, and at the same time beets are capable to lower your estrogen levels by acting as a methylate, as explained here.

11. Cranberries

There are countless of health benefits that link back to cranberries. Possibly one of the less known ones is the fact that cranberries increase nitric oxide production, while lowering blood pressure significantly at the same time. This was found out by a study conducted back in the year 2000.

10. Garlic

Researchers say that garlic is a potent activator of NOS (nitric oxide synthase), and produces same kind of effects as Cialis or Viagra. In one study it was noted that garlic decreased systolic and diastolic blood pressure by 8 points on subjects with high blood pressure. That’s a very impressive result from a food, as it shows to be working even better than most of the high blood pressure medications.

9. Black tea

contains caffeine, which acts as a vasoconstrictor, and that’s the main reason why black tea is not something you usually see on a list of foods that increase nitric oxide. But despite black teas caffeine content, it still has some major vasodilation effects. Many studies claim that black tea significantly increases nitric oxide production and lessens the arterial stiffness. On top of that there is this study done back in 2009 which claims that more black tea = more blood flow.

8. Cayenne pepper

contains high amount of capsaicin, the compound that makes all chili’s hot. One study noted that capsaicin has a dose dependent effect, meaning that more the subjects consumed capsaicin, the more their nitric oxide levels increased and arteries relaxed.

7. Honey

One animal study claims that honey significantly increases nitric oxide production. Either the high enzyme content probably causes this, or the high nitrate content that honey has.

6. Pistachios

Like almost all nuts, pistachios are also packed with L-Arginine, a precursor of nitric oxide that is known for its ability to increase nitric oxide production significantly.

5. Salmon

Wild salmon is a very good source of co-enzyme Q10, enzyme that can be spotted on moisturizer adds for women. Co-enzyme Q10 is not only great for soothing wrinkles; it’s also a very good nitric oxide booster as it has been shown in dozens of studies to increase nitric oxide production significantly.

4. Kale

Kale is also a very good source of co-enzyme Q10 that boosts nitric oxide. Kale also has very high nitrate content, which makes it very good nitric oxide booster. There are also many other health benefits linked to kale, such as increased testosterone levels and improved arterial health.

3. Animal Organs

One of the greatest foods that every man should be consuming are foods like animal liver. The organs contain high amounts of cholesterol and healthy fat-soluble vitamins that boost your testosterone levels. Those organs are also very good source for co-enzyme Q10 that increases nitric oxide levels, so it’s a win-win situation if you eat organs!

2. Onions

Onions are not only good for your testosterone levels, as they have been shown to increase nitric oxide production in 2 different studies. They are also a very good source of vitamin C, which as explained above protects your nitric oxide molecule from free radicals. Onions also contain a compound called Quercetin, explained briefly here. Quercetin is well known for its ability to boost nitric oxide levels.

1. Shrimp:

One of the best sources of dietary L-Arginine, as mentioned above L-Arginine is an amino acid and precursor of nitric oxide. By consuming shrimps you are essentially increasing the amount of L-Arginine in your body which then converts into nitric oxide.

 

Physiotherapy Equipment Market Is Expected To Grow At A Cagr Of 6.35% By 2020

Physiotherapy is a technique that uses various procedures and equipment to relieve physical ailments. It has evolved from a simple massage to a complex variety of treatments. It is an essential part of rehabilitation after surgeries, chemotherapy, and radiation procedures to promote mobility. Physiotherapy plays a significant role for physically challenged people and provides relief to the patients with injuries and chronic disorders such as stroke, arthritis, and cerebral palsy.

Browse the full report @: https://www.marketresearchengine.com/upcommingreport/global-physiotherapy-equipment-market-research-study

How Big is the Global Physiotherapy Equipment Market?

The global physiotherapy equipment market to grow at a CAGR of 6.35% over the period 2014-2020.

The report covers the current scenario and the growth prospects of the global physiotherapy equipment market for the period of 2015-2020. To calculate the market size, the report considers revenue generated through sales of the following product categories:

Equipment
Accessories

Table of Contents

INTRODUCTION
2 Research Methodology

3 Executive Summary

4 Premium Insights

5 Market Overview

6 Industry Insights

7 Physiotherapy Equipment Market,By Product

8 Physiotherapy Equipment Market, By Application

9 Physiotherapy Equipment Market, By End User

10 Geographic Analysis

11 Competitive Landscape

12 Company Profiles

12.1 Introduction

12.2 Djo Global/ Chattanooga

12.3 EMS Physio Ltd.

12.4 ENRAF-Nonius B.V.

12.5 BTL Industries Inc.

12.6 Isokinetics , Inc.

12.7 Patterson Companies Inc.

12.8 Morris Group Internationals

12.9 HMS Medical Systems

12.10 Dynatronics Corporation

12.11 Body Sport

 

Perioperative Physiotherapy in Total Knee Arthroplasty

Melvin G. Joice, BSE; Subhrojyoti Bhowmick, MD; Derek F. Amanatullah, MD, PhD

Orthopedics
Posted May 22, 2017
DOI: 10.3928/01477447-20170518-03

Abstract

Total knee arthroplasty has a high success rate. In the interest of enhancing patient outcomes, numerous perioperative interventions have been studied, including preoperative education, preoperative rehabilitation, postoperative inpatient rehabilitation, continuous passive motion, postoperative outpatient rehabilitation, unsupervised in-home exercises, telerehabilitation, and various combinations of these. This comprehensive review analyzes the existing body of evidence on these perioperative interventions and examines some burgeoning opportunities in rehabilitation after total knee arthroplasty in the interest of improving patient outcomes and ensuring sustainable health care utilization for the future of total knee arthroplasty. [Orthopedics. 201x; xx(x):xx–xx.]

Total knee arthroplasty (TKA) is the gold standard of treatment for patients with end-stage arthritis of the knee. As of 2010, more than 620,000 TKA procedures were performed annually in the United States.1 By 2030, this is predicted to reach 3.5 million annually.2 Even with these high volumes, the 2003 National Institutes of Health consensus statement on TKA concluded that “the use of rehabilitation services is perhaps the most under-studied aspect of the perioperative management of TKA patients . . . [and] there is no evidence supporting the generalized use of any specific pre-operative or post-operative rehabilitation intervention.”3 In response to this statement, investigators have reported on a plethora of rehabilitative techniques and regimens available for perioperative management of TKA patients. In the United States, rehabilitation after TKA refers to several different practice settings depending on the patient, the health care system, and treatment decisions made by both the health care team and the patient. “Rehabilitation” begins at or before entering the acute inpatient setting, where decisions are made concerning the most appropriate discharge location for the patient. Possible discharge locations for a patient after TKA are a skilled nursing facility, an inpatient rehabilitation facility, home with home health physical therapy, home with a prescribed home exercise program, or outpatient physical therapy.4 Müller et al5 observed that best practice in rehabilitation is largely based on clinical experience, local customs, anecdotal evidence, surgeon preferences, clinical pathways established for the acute-care phase of recovery, and health insurance funding schemes.

This review reports the numerous available rehabilitation options, highlights the regimens with the highest level of evidence-based consensus, and examines some burgeoning opportunities in rehabilitation that may be necessary to keep pace with the increasing demand for TKA.

Materials and Methods
Search and Selection

In May 2016, a thorough search was conducted of MEDLINE (from 1966), the Cochrane Library, and the Physiotherapy Evidence Database (PEDro). Included were studies published in English, concerning perioperative interventions for primary TKA, with well-established outcome measures, considered randomized controlled trials (RCTs), with a matched cohort, considered comparative retrospective case series, and considered applicable Cochrane reviews and meta-analyses. Excluded studies included those with data not reported, those with nonquantitative outcome measures, or those published prior to 1985. Search terms included total knee arthroplasty, physiotherapy, rehabilitation, management, preoperative, postoperative, continuous passive motion, telerehabilitation, in-home exercises, neuromuscular electric stimulation, diet, and Wii as isolated terms and in combination.

Data Analysis

For specific interventions that had sufficient data, a forest plot was constructed to analyze effectiveness. Only continuous passive motion (CPM) as an intervention had enough data in the existing literature to be analyzed. Any study since 1990 that had adequate reporting of data to analyze was included. Of the 28 studies found concerning CPM, 17 were included.6–22 Eleven studies were not included, mainly due to incomplete data reporting.23–34 Of the excluded studies, some did not report standard deviations, others did not use a standard protocol for the measurement of range of motion (ROM), and one was out-side the date range specified in the inclusion criteria.

To generate the forest plots, the standardized mean differences between treatment groups on each outcome were calculated at each time point for which data were available, as well as 95% confidence intervals for these effects. These effect size estimates were then pooled across the subset of studies making the same treatment comparisons at the same time points using standard random effects meta-analytic methods. All analyses and plotting were accomplished using the rmeta, meta, and es.compute libraries of the R statistical program (version 3.0.0; R Foundation) released in 2014.

Discussion
Preoperative Interventions

Preoperative Patient Education. Pre-operative education refers to any educational intervention delivered before surgery that aims to improve the patients’ knowledge, perspectives, health behaviors, and/or health outcomes.35–37 Although the content of preoperative education varies, it often includes discussion of administrative procedures, the surgical procedure, postoperative care, potential stressful scenarios, potential complications, pain management, and movements to perform or avoid after surgery.38

Chen et al39 randomized patients (n=92) to receive either a pamphlet or educational videos and a skill-teaching session for rehabilitation or usual standard care. Patients receiving the additional materials reported lower pain scores up to 2 days postoperatively; after that, the only significant differences were in stair climbing time, eating, and the regularity of performing straight-leg raises. Crowe and Henderson40 provided patients (n=133) with a 50-minute video, an informational booklet, a tour of the postoperative hospital unit, and a demonstration of how to use the postoperative equipment. Although they found that length of stay (LOS) could be reduced by offering comprehensive individualized educational materials for patients, they did not find significant differences in joint flexion, the 30-minute walking test, or stair climbing.40 Encompassing 12 similar studies (n=1567), a systematic review conducted in 2015 analyzed the effect of preoperative education on anxiety, pain, LOS, patient satisfaction, postoperative complications, mobility, and expectations. Among these outcomes, preoperative education was only found to be effective in reducing preoperative patient anxiety.41

Current evidence seems to indicate that a focus on preoperative education has little clinical benefit. Although preoperative education should remain a part of the clinical pathway in TKA, no extra resources or time apart from the standard of care seems to be indicated currently.

Physiotherapy/Prehabilitation. Preoperative physiotherapy or “prehabilitation,” whether in a home setting or a clinical setting, is theorized to improve postoperative TKA outcomes by increasing knee ROM and strengthening the quadriceps muscles before surgery. A graphical representation of this theory, similar to one presented by Ditmyer et al,42 is shown in Figure 1.

Proposed prehabilitation model. It is postulated that rehabilitation before surgery results in better postoperative outcomes. Abbreviation: TKA, total knee arthroplasty.


Figure 1:
Proposed prehabilitation model. It is postulated that rehabilitation before surgery results in better postoperative outcomes. Abbreviation: TKA, total knee arthroplasty.

In 2007, Williamson et al43 (n=181) administered a 6-week course of preoperative physiotherapy that included “static quadriceps contractions, inner range quadriceps contractions, straight leg raises, sit-to-stands, stair climbing, calf stretches, theraband resisted knee extensions, wobble board balance training, knee flexion/extension sitting on gym ball, and free-standing peddle revolutions.” They found no significant differences in LOS, Oxford knee score, 50-minute walking test, visual analog scale score, or Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score. Mitchell et al44 conducted an RCT (n=160) comparing patients who received preoperative and postoperative physiotherapy with those who received only postoperative physiotherapy. Preoperative physiotherapy included pain relief, techniques to increase knee flexion and extension, gait reeducation, and functional adaptations.44 For all outcome measures, including WOMAC, stiffness, and Short Form-36 scores, the authors found no significant differences for patients receiving the extra preoperative physiotherapy.

Contrastingly, some studies have found significant short-term differences in post-operative outcomes when administering preoperative physiotherapy to TKA patients. In 2014, Matassi et al45 randomized patients (n=122) to either receive a preoperative 6-week home-based exercise program or continue normal activities until surgery. With a 79% compliance rate with the at-home regimen, the authors concluded that preoperative home-based exercise offered a boon in short-term knee ROM, but had no significant effect on knee ROM or Knee Society score 1 year after TKA.45

Despite the body of evidence mounting against both preoperative education and preoperative physiotherapy individually, it was hypothesized that combining these interventions might offer superior post-operative outcomes in TKA. Beaupre et al46 randomized patients (n=131) to either a combined education/exercise program that consisted of 3 sessions for 4 weeks preoperatively or a control group that received usual care. They found no significant differences in ROM, pain, function, or health-related quality of life up to 1 year after TKA.46

Overall, recent reviews and meta-analyses unanimously agree that patient outcomes are not significantly affected in the long-term by preoperative physiotherapy regimens.47–49 Wallis and Taylor49 hypothesized that preoperative physiotherapy shows little effect because “it is possible that marked reduction of pain that comes from replacing painful joint surfaces during surgery far outweighs modest contribution from pre-operative interventions.” An alternative hypothesis is that patients are so significantly deconditioned from the surgery that any benefits gained from preoperative rehabilitation are muted.50 The revised model for the effects of preoperative physiotherapy is shown in Figure 2. Currently, preoperative rehabilitation is rarely prescribed by surgeons because of the lack of long-term postoperative benefits.51

Figure 2:
Actual prehabilitation model. By current evidence, rehabilitation before surgery does not affect postoperative outcomes. Abbreviation: TKA, total knee arthroplasty.

Short-term Postoperative Interventions

Inpatient Rehabilitation. Inpatient rehabilitation refers to any intervention that follows immediately after TKA and prior to initial discharge. Although there is large consensus on the importance of a rehabilitation regimen immediately following TKA, little agreement exists on the exercises that comprise the regimen, the intensity of exercises, and the duration. Recent regimens reported in the literature vary in duration from 3 to 14 days and have employed interventions such as walking, stretching, gait retraining, CPM, aquatic therapy, quadriceps strengthening exercises, and stair climbing exercises. Contemporary inpatient regimens have shorter durations and more intense exercises and begin on the day of surgery or the first postoperative day.

Aggressive rehabilitation is believed to be important in preventing postoperative contracture of the soft tissue and in gaining better flexion postoperatively. Pua and Ong52 (n=1504) studied the significance of ambulation on the first postoperative day and found that it resulted in a significantly shorter LOS, lower hospitalization costs, and improved knee function. Zietek et al53 (n=66) increased the intensity of rehabilitation on the first postoperative day by adding an extra 15-minute walk with a walker 3 hours after an initial 15-minute walk. They found no detriment to the added intensity and suggested a further increase in intensity. However, when Lenssen et al54 (n=43) increased inpatient rehabilitation intensity to 2 physical therapy sessions a day in an RCT, they found no significant gain in ROM.

Isaac et al55 randomized patients (n=50) to investigate an accelerated rehabilitation protocol that included infiltration of bupivacaine and adrenaline into the divided tissue layers at the time of surgery, spinal anesthesia, mobilization on the day of surgery, an organized multidisciplinary approach anticipating issues that may delay discharge, and an expectation of an earlier discharge from the hospital. They showed a 6.9-day decrease in LOS, with comparable pain levels, Knee Society score, and Oxford knee score. Similarly, in a randomized clinical trial (n=185), a rapid recovery protocol after TKA was tested in a low-resource military hospital setting; the protocol included preoperative patient education, ambulation on the first postoperative day, and pain management with celecoxib and oxycodone.56 The protocol decreased LOS by 2.9 days and saved an average of $1511 in hospitalization costs without causing any adverse health outcomes.

Overall, inpatient rehabilitation in the immediate postoperative setting is the most important intervention in perioperative management of TKA. In recent years, the regimens have become shorter and more aggressive, including postoperative ambulation on the day of surgery or the first day following surgery. There is evidence to indicate that shorter courses of rehabilitation do not adversely affect patients and are beneficial in terms of LOS and hospitalization costs.

Continuous Passive Motion. The mechanism of CPM has been hypothesized to be twofold: facilitating the movement of synovial fluid to allow for better diffusion of nutrients into damaged cartilage with diffusion of other materials out, and preventing fibrous scar tissue formation in the joint, which tends to decrease ROM.

Studies on the use of CPM have had conflicting results. Early studies indicated that CPM had a short-term benefit after TKA by increasing knee ROM and improving wound healing.27 Other studies purported that CPM may be optimized if initiated immediately after TKA.11,15,23,31,57 However, more recent studies seem to refute these findings, claiming no benefit in CPM after TKA.6–8,18–20,28,29,32–34,58 In an attempt to make sense of the conflicting evidence, several systematic reviews have been conducted. However, these reviews have had conflicting conclusions as well. Older reviews seem to favor the use of CPM,59.60 while more recent reviews seem to show no benefit.61,62

Conflicting conclusions of the systematic reviews were a result of different inclusion and exclusion criteria. Reviews that included studies in which post-TKA patients who received CPM were compared with patients whose knees were immobilized found a benefit with CPM. Contrastingly, reviews that only included studies in which patients who received CPM were compared with patients who received conventional physiotherapy found no benefit with CPM. This difference in comparison explains why earlier reviews found CPM to be beneficial—they were conducted at a time when the standard of care for acute postoperative TKA was knee immobilization. More recent reviews compared CPM with the current standard of care, physiotherapy, and found no difference. Thus, critical scrutiny of the literature against the backdrop of normal clinical practice provides a unified conclusion supporting postoperative rehabilitation in TKA, in the form of conventional physiotherapy or CPM, because knee motion is more beneficial than knee immobilization. Further, this unified conclusion supports the idea that CPM offers little to no additional benefit to conventional postoperative physiotherapy.

To validate the unifying theory concerning discordant conclusions in CPM studies and meta-analyses, forest plots were generated that stratified the control group to either postoperative immobilization or physical therapy. In the CPM vs immobilization data analysis, ROM was analyzed at time points of 3 and 12 months (Figure 3). The pooled data showed no significant ROM improvement at either time point. In the CPM vs physical therapy data analysis, the time points included discharge, 3 months, 6 months, and 12 months (Figure 4). Regardless of time point, none of the changes in ROM represented a clinically significant difference with the use of CPM when compared with the use of physical therapy.

Continuous passive motion (CPM) vs immobilization (IM) at 3 months and 12 months. With just a few studies, conclusions are difficult to draw. However, a few studies found CPM, compared with IM, to be helpful in increasing range of motion. Abbreviation: CI, confidence interval.

Figure 3:
Continuous passive motion (CPM) vs immobilization (IM) at 3 months and 12 months. With just a few studies, conclusions are difficult to draw. However, a few studies found CPM, compared with IM, to be helpful in increasing range of motion. Abbreviation: CI, confidence interval.

Continuous passive motion (CPM) vs physical therapy (PT) at discharge, 3 months, 6 months, and 12 months. At all time points, CPM was not found to be helpful in increasing range of motion. Abbreviation: CI, confidence interval.


Figure 4:
Continuous passive motion (CPM) vs physical therapy (PT) at discharge, 3 months, 6 months, and 12 months. At all time points, CPM was not found to be helpful in increasing range of motion. Abbreviation: CI, confidence interval.

Comparing the 2 stratified analyses, the largest absolute mean difference was seen in CPM vs immobilization at 12 months. This offers some insight into why CPM was thought to be beneficial when compared with immobilization but not when compared with physical therapy. Overall, the authors’ analysis of current literature suggests that there is little benefit to any patient receiving CPM after primary TKA in the backdrop of the current standard of care that includes postoperative physical therapy, indicating that CPM is an unnecessary overuse of medical resources.

Long-term Postoperative Interventions

Outpatient Physical Therapy. Physical therapy that begins after hospital discharge has long been considered the standard of care in the rehabilitation after TKA, reliably facilitating ROM, strength, and quality of life improvements. Outpatient rehabilitation can range from 3 to 8 weeks and can include multiple sessions per week. Ebert et al63 (n=108) noted that active knee flexion at the beginning of outpatient visits correlates strongly with knee flexion at 7 weeks after TKA, underscoring the importance of rehabilitation even after hospital discharge. Similarly, Brennan et al64 (n=321) recently reported that an increase in the number of days between hospital discharge and outpatient physical therapy was a significant factor in the prediction of disability and pain scores at the completion of rehabilitation, with an increase in the number of days correlating with an increase in pain and disability. In a survey of physiotherapists concerning best practices for rehabilitation, participants agreed that “aggressive physiotherapy should be met within 8 weeks, as the knee can become stiff as a result of tissue scarring down from lack of mobility.”65

A key research issue, of recent importance due to the increased demands placed on rehabilitation services, has been the use of group physical therapy vs individual physical therapy. Naylor et al66 surveyed 93 TKA patients after their rehabilitation was complete and found no overall preference for either mode. The authors also confirmed the strengths of each mode: group-based therapy granted a psychosocial benefit, whereas the one-to-one therapy offered a more personalized approach. Aprile et al67 conducted a randomized, single-blind, crossover study (n=27) comparing individual and group rehabilitation. They found no significant differences in Short Form-36, WOMAC, and visual analog scale scores between patients at 1 month after TKA.67 Similarly, Ko et al68 conducted a randomized, superiority trial (n=249) comparing one-to-one therapy, group-based therapy, and a monitored home program. They found that “one-to-one therapy does not provide superior self-reported or performance-based outcomes compared with group-based therapy or a monitored home program, in the short term and the long term after total knee arthroplasty.”68 The outcome measures included the Oxford knee score, WOMAC score, and Short Form-12 score.

Outpatient physical therapy remains relevant in the clinical pathway following primary TKA; however, current trends indicate a shift toward patient-specific regimens. Because evidence suggests both group therapy and individual therapy are viable options, patients can be assigned according to their individual preferences concerning physical therapy.

Home Exercises and In-Home Telerehabilitation. Both home exercise regimens delivered via a physician handout containing diagrammed exercises and telerehabilitation involving physical therapists interacting via live, 2-way video feeds have recently garnered attention as resource-saving rehabilitation modalities.

According to Dr Froimson, President of the Cleveland Clinic Health System, “The goals of a home-based clinical care path . . . include patient and family engagement, shared decision-making, and flexibility regarding changes in plans to accommodate changing needs.”69 He continued, “Patients discharged home consume significantly fewer resources and cost the system about one-third as much as those sent to an inpatient postacute facility.” In a recent RCT (n=34), Buker et al70 compared supervised physiotherapy with home exercises. They found no differences in visual analog scale score, ROM, WOMAC score, and Short Form-36 score between the groups and noted that home exercises were approximately $209 less expensive. Similarly, Rajan et al71 randomized patients (n=120) to receive either usual-care physiotherapy or a well-structured home exercise regimen. At 1-year follow-up, only a clinically insignificant difference of 2.9° in ROM was seen. Kramer et al72 randomized patients similarly (n=160) and found no significant differences in Knee Society score, WOMAC score, Short Form-36 score, 6-minute walking test, 30-second stair climbing time, and knee flexion ROM at 3 months and 1 year after TKA. Han et al73 confirmed these findings in a multicenter, noninferiority RCT (n=490). They reported no significant differences in pain, knee function, ROM, or 50-foot walk times at 6 weeks postoperatively. Home-based care, as per current evidence, is a viable and more efficient alternative to outpatient rehabilitation.

Telerehabilitation is a newer medium for postoperative rehabilitation; advances in technology and Internet availability have made wider use of these technologies possible. Russell et al74 conducted an RCT (n=65) evaluating the equivalence of an Internet-based telerehabilitation program with conventional outpatient physical therapy. The authors noted comparable ROM, muscle strength, limb girth, pain, timed up-and-go, quality of life, gait, and WOMAC scores. They also noted that the telerehabilitation intervention was well received by participants, who reported a high level of satisfaction with this novel technology.74 Similarly, a higher-powered RCT (n=205) that compared face-to-face home rehabilitation with telerehabilitation found the latter to be noninferior in terms of WOMAC score, knee injury and osteoarthritis outcome score, knee function, knee strength, and ROM.75 Examining cost concerns, Tousignant et al76 used an RCT (n=197) to compare telerehabilitation with home-visit rehabilitation. The authors found telerehabilitation to be less expensive via a total cost analysis—a differential of -$263 (95% confidence interval, -$382 to -$143) in Canadian dollars.76 However, in lieu of a net analysis, telerehabilitation was only significantly less expensive when the patient lived more than 30 km from the health care center. Telerehabilitation offers yet another way for health care professionals to account for patient-specific factors in prescribing postoperative physical therapy. For patients with the technological accessibility and savvy, a telerehabilitation regimen may be indicated.

Adjunctive Interventions

Neuromuscular Electric Stimulation. In an attempt to improve TKA outcomes, an array of adjunctive interventions is under investigation. Neuromuscular electric stimulation (NEMS) involves electrical stimulation of lower limb muscles using a transcutaneous electrical nerve stimulation system. Neuromuscular electric stimulation is hypothesized to improve muscle strength of the quadriceps and to train patients without sufficient volitional quadriceps activation by engaging neuro-physiological mechanisms after TKA.77

Levine et al,78 in an RCT (n=70), showed that NMES combined with unsupervised at-home exercises was noninferior to traditional supervised physiotherapy at 6 months postoperatively regarding flexion, extension, Knee Society score, WOMAC score, and timed up-and-go. In a small RCT (n=30), Avramidis et al79 applied NMES to the vastus medialis for 6 weeks postoperatively as an adjunct to conventional physical therapy. The authors found a significant increase in walking speed at 3 months, but the Hospital for Special Surgery knee score was unchanged.79 Similarly, Demircioglu et al80 (n=60) applied an adjunctive NMES protocol—5 days a week for 4 to 6 weeks—to a standard exercise protocol in an RCT. They found that NMES improved ROM and timed up-and-go at 1 month but not at 3 months postoperatively. They also measured better WOMAC scores at both 1 and 3 months. The authors concluded that NMES therapy added to a standard exercise protocol offers superior outcomes.80 Although few studies have examined the long-term effects of NMES, in a small RCT (n=35), Stevens-Lapsley et al81 noted that improvements in quadriceps strength, hamstring strength, stair climbing time, timed up-and-go, and 6-minute walking test persisted until 1 year after TKA. In a high-powered RCT (n=200), Petterson et al82 showed that strength, activation, and function were similar between the exercise and exercise–NMES groups at 3 and 12 months. However, both groups were stronger and exhibited better function than the standard-of-care group at both time points.

Overall, NMES is a relatively new modality in the postoperative course of primary TKA. Preliminary evidence suggests a slight improvement in clinical outcomes with the use of NMES.

Wii-Based Home Rehabilitation. Balance training has been included in rehabilitation after TKA.83,84 Given the recent prevalence of Wii (Nintendo, Kyoto, Japan) console systems in homes and the inclusion of Wii Fit, the concept of Wii-based home rehabilitation via balance training has emerged as an adjunct to traditional physiotherapy. Wii Fit games encourage lower extremity movement, challenge balance, and require players to remain in a standing position during play—activities that have the potential to address rehabilitation goals involving recovery of lower extremity function.85 McPhail et al86 (n=18) conducted a preliminary trial in patients recovering from lower limb fractures. The Wii Fit regimen failed to show clinically meaningful differences in a range of measurements, including gait parameters, lower extremity functional scale, and step test.86 Similarly, in an RCT (n=50), Fung et al85 administered 15-minute sessions of Wii Fit after traditional physical therapy sessions. They found no significant differences between the groups regarding pain, knee flexion, knee extension, walking speed, timed standing tasks, lower extremity functional scale, activity-specific balance confidence scale, and patient satisfaction with therapy services.85

Clinical Relevance

In the lengthy clinical pathway from scheduling a patient for TKA to the patient’s resuming normal activity, many options—old and new—exist in the interest of maximizing patient outcome. Overall, evidence seems to suggest that preoperative rehabilitation and education are unsuccessful at enhancing outcomes. Inpatient rehabilitation remains a mainstay before releasing a patient and is effective. Continuous passive motion has been heavily investigated without much consensus, but the current authors’ analysis along with recent evidence supports the conclusion that CPM offers little benefit to primary TKA patients in lieu of standard-of-care physical therapy. Outpatient rehabilitation is incredibly popular. However, given its cost, inconvenience, and increased load on limited health care resources, outpatient rehabilitation is being slowly replaced by unsupervised home exercises and telerehabilitation without any adverse effects. Adjunctive therapies such as NMES have begun to emerge, but their long-term advantage needs to be substantiated. New opportunities such as mobile application–based physical therapy hold promise in enhancing patient satisfaction and reducing health care resource utilization by granting increased autonomy, digitizing patient management, identifying outliers for more intensive therapy, and potentially enhancing outcomes. These new opportunities require further investigation and hold promise for a health care utilization scheme that can adequately manage the increasing demand for TKA services.

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Brennan GP, Fritz JM, Houck LT, Hunter SJ. Outpatient rehabilitation care process factors and clinical outcomes among patients discharged home following unilateral total knee arthroplasty. J Arthroplasty. 2015; 30(5):885–890. doi:10.1016/j.arth.2014.12.013 [CrossRef]
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Stevens-Lapsley JE, Balter JE, Wolfe P, Eckhoff DG, Kohrt WM. Early neuromuscular electrical stimulation to improve quadriceps muscle strength after total knee arthroplasty: a randomized controlled trial. Phys Ther. 2012; 92(2):210–226. doi:10.2522/ptj.20110124 [CrossRef]
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McPhail SM, O’Hara M, Gane E, Tonks P, Bullock-Saxton J, Kuys SS. Nintendo Wii Fit as an adjunct to physiotherapy following lower limb fractures: preliminary feasibility, safety and sample size considerations. Physiotherapy. 2016; 102(2):217–220. doi:10.1016/j.physio.2015.04.006 [CrossRef]
Authors
The authors are from the Albert Einstein College of Medicine (MGJ), Bronx, New York; and Stanford University School of Medicine (SB, DFA), Redwood City, California.
Mr Joice and Dr Bhowmick have no relevant financial relationships to disclose. Dr Amanatullah is a paid consultant for Omni, Exactech, Blue-Jay Mobile Health, Stryker, Medscape, and Sanofi and has received grants from BlueJay Mobile Health and Stryker.
Correspondence should be addressed to: Derek F. Amanatullah, MD, PhD, Stanford University School of Medicine, 450 Broadway St, M/C 6342, Pavilion C, 4th Fl, Redwood City, CA 94063 ( dfa@stanford.edu).

Copyright 2017, SLACK Incorporated

Received: June 16, 2016
Accepted: October 31, 2016
10.3928/01477447-20170518-03

 

23 million Americans to lose health insurance

An estimated 23 million people would lose health coverage by 2026 under Republican legislation aimed at repealing Obamacare, a nonpartisan congressional agency said on Wednesday in the first calculation of the new bill’s potential impact. Chris Dignam reports.

The House Republican healthcare bill passed earlier this month will leave 23 million more Americans without health insurance.

That’s the latest estimate from the U.S. Congressional Budget Office, which released its findings Wednesday afternoon. The new number down minimally from the estimated 24 million people who would lose health insurance by 2026 in the CBO’s score of the previous House bill.

Republicans facing harsh criticism since passing their health bill from Democrats and in town halls across the country. The backlash likely to escalate as the CBO concluded the number of uninsured was only reduced by 1 million people and that premiums will vary significantly.

The report also saying that the bill would cut the federal deficit by 119 billion dollars between now and 2026. That calculation opens the door for Congress to pass the bill through a process called reconciliation, which requires only a simple majority instead of a full two-thirds of votes in the Senate. Republicans hold a 52-48 majority.

Soon after the release of the new CBO score the minority voicing its opposition.

(SOUNDBITE) (English) U.S. SENATE DEMOCRATIC LEADER CHUCK SCHUMER SAYING:

“The report makes clear Trump Care would be a cancer on the American health care system.”

A group of 13 Republican senators led by Mitch McConnell have said they’ll be rewriting their own version of the healthcare bill in the coming months. The majority leader telling Reuters Wednesday: “I don’t know how we get to 50 at the moment. But that’s the goal.”

 

Balloon capsules can help obese patients lose weight faster

Obese patients who swallowed balloon capsules that helped them eat less lost an average of 15 pounds, roughly two times more weight than patients who just dieted and exercised, researchers report.

obeseThe capsule was inflated with gas via a catheter when it reached the stomach. As many as three balloons were placed over three months, and all of the balloons were removed after six months. The balloons made patients feel full, the researchers explained.

In addition to the balloons, patients followed a moderate diet and behavior modification program. Whether the weight loss will last over the long term isn’t known, said lead researcher Dr. Aurora Pryor, director of the Bariatric and Metabolic Weight Loss Center at Stony Brook University in New York.

The study lasted a year, but “we don’t know what happens after that,” Pryor said.

“If they are able to stick to their newfound lifestyle with their diet and exercise program, they could maintain their weight loss,” she said. “The long-term results are dependent on patients keeping their motivation to stay with their diet and exercise programs.”

The balloon treatment will be available starting in January, but the cost hasn’t been announced, Pryor said. The device, called the Obalon Balloon System, was approved in September by the U.S. Food and Drug Administration.

An advantage of the balloons is that patients have no downtime and can go back to work the same day, the researchers said.

“There is no sedation or recovery time when the balloons are placed, but there is sedation when the balloons are removed, so you wouldn’t want to go back to work after that,” Pryor added.

Pryor believes balloons are a better option for patients who are candidates for weight loss surgery but don’t want surgery. “For people who want to lose some weight but don’t feel they are heavy enough for surgery or they’re afraid of surgery, this is a really good next step to help them jump start their weight loss,” she suggested.

The findings were to be presented Friday at the annual meeting of the American Society for Metabolic and Bariatric Surgery and the Obesity Society in New Orleans. Research presented at meeting is considered preliminary until published in a peer-reviewed journal.

One weight-loss expert expressed some doubts about the findings.

“I still question the efficacy of balloons,” said Dr. Mitchell Roslin, chief of obesity surgery at Lenox Hill Hospital in New York City. “While there is potentially easier insertion that does not require sedation, I still doubt after removal there will be weight loss,” he said.

Roslin said patients who have other treatments that restrict their ability to eat — such as bands and bypass operations that reduce the size of the stomach — often regain lost weight over time. “As time goes on, weight loss will be about lifestyle changes,” he said.

The only argument for the balloon is that it starts the lifestyle changes, Roslin said. “It may make it easier to become motivated,” he said. “But I believe that few will maintain weight loss two years after any balloon.”

For the study, Pryor and her colleagues randomly assigned nearly 400 obese patients to receive a real or sham device. All patients also had 25 minutes of lifestyle therapy every three weeks. After six months, patients with the Obalon balloons had them removed.

During the time patients had the balloons, and for six months after, the researchers monitored their weight loss. The investigators also followed those who had not received the balloon therapy.

People treated with the balloons lost an average of 7 percent of their weight, compared to less than 4 percent for those who received the sham device, the researchers found. Six months after the balloons were removed, nearly 90 percent maintained the weight loss they achieved during treatment, Pryor said.

As for side effects, one patient had a bleeding stomach ulcer while taking high doses of pain pills after a knee replacement. Most patients (91 percent) suffered from stomach cramps and nausea, which nearly 100 percent said were mild or moderate.

The results were also presented at a medical meeting in May.

One health and nutrition expert noted that a balloon does not equal a lifestyle change.

“A gastric balloon may help with weight loss, but will do nothing to improve diet quality and overall health,” said Dr. David Katz. He is director of the Yale-Griffin Prevention Research Center in Derby, Conn., and president of the American College of Lifestyle Medicine.

The role for such technology-based approaches to weight control should be a small one, he said.

“Such devices may be alternatives to bariatric surgery in some cases. But they should not distract us from the far better solution at the population level: practices, programs and policies that make eating well and being active a cultural norm,” Katz said.

 

Heat stroke

Heat stoke is a very serious medical condition that happens when the body overheats and is unable to cool down without external help. It causes at least 240 deaths in the United States each year, according to the American Academy of Family Physicians.

Causes & symptoms

Heat stroke, a form of hyperthermia, is characterized by a core body temperature of 104 degrees Fahrenheit (40 degrees Celsius) or greater. “When suffering from heat stroke, the body’s natural temperature regulation process is overwhelmed by the external heat,” said Dr. Erik Polan, an internal medicine doctor at Philadelphia College of Osteopathic Medicine. “Organ systems may become damaged due to dehydration and elevated internal temperature, which can be lethal.”

There are two types of heat stroke. One is generally seen in older patients during heat waves. This is known as classical heat stroke (CHS). The other is seen in younger people who are exerting themselves in a hot, humid environment. This type is known as exertional heat stroke (EHS), explained Dr. Neha Raukar, an associate professor of emergency medicine at Brown University.

While EHS comes on quickly, CHS can take two to three days of exposure to heat to develop, according to the Merck Manual.

According to the U.S. National Library of Medicine, heat cramps — usually muscle cramps in the leg or abdomen — are the first sign of heat stroke. Other symptoms include fainting, dizziness, confusion, lightheadedness, fatigue, headache, nausea, vomiting, loss of consciousness and unusual behavior such as aggression. The person may also have hot, dry or red skin, an increased heart rate and/or a change in their breathing.

Treatment

A person with possible heat stroke must be treated immediately. The extreme heat can damage the heart, brain, kidneys and muscles very quickly. The longer it is left untreated, the worse the damage can become.

“As a neurosurgeon, I feel passionate about raising awareness of EHS, as this condition can cause long-term damage to the brain,” said Dr. Julian Bailes Jr., director of the department of neurosurgery and co-director of the NorthShore University HealthSystem Neurological Institute. “I’ve found that too often, people ignore the warning signs of overheating and their condition turns into a potentially life-threatening medical emergency – EHS – which can threaten organ function or life itself.”

To begin treatment, first call 911, and then move the person to a cooler area, if possible. Remove as much clothing as possible and apply cool, wet cloths to the skin to help lower their body temperature. Applying ice packs to the body is also helpful. If the person is conscious, getting them to drink water is also important.

Once in professional care, medical professionals may immerse the patient in cold water, use evaporation cooling techniques, pack the patient in ice or wrap the body in a cooling blanket. Ice packs may also be applied to the neck, groin, back and armpits to lower the body temperature, according to the Mayo Clinic. Medications to stop any shivering, like muscle relaxants, may also be given to the patient since shivering can raise the body temperature, which is at odds with the goals of the treatment.

After treatment, the patient will be required to stay only in cool areas to prevent a relapse.

Prevention

It’s important to take preventive measures to avoid heat stroke. “Those most at risk for heat stroke are children, the elderly who may live alone, those with chronic medical issues, and those who participate in strenuous activity outdoors,” said Polan.

Some strenuous activities include mowing the lawn, dancing at concerts and exercising outside. While working or exercising in hot temperatures, wear loose, light clothing to reflect light and help encourage airflow for better sweat evaporation. Also, take regular breaks, stay hydrated and try to schedule outdoor work before 10 a.m. and after 3 p.m. to avoid the hottest part of the day.

Being informed about what medications and substances can contribute to heat stroke is also useful. According to the American Academy of Family Physicians, these include:

  • Alcohol
  • Amphetamines
  • Anticholinergics
  • Antihistamines
  • Benzodiazepines
  • Beta blockers
  • Calcium channel blockers
  • Cocaine
  • Diuretics
  • Laxatives
  • Neuroleptics
  • Phenothiazines
  • Thyroid agonists
  • Tricyclic antidepressants

Don’t forget about helping others. Check in on loved ones and neighbors who are in these high-risk groups, and be particularly mindful of small children — never, ever leave a child unattended in a hot car, even for a moment, advised Polan.

From 1990 to 2016, 793 children died of heat stroke after being left in a hot car. The temperature in a car can rise 20 F (11 C) in 10 minutes when parked in the sun, according to the Mayo Clinic. Even in the shade with the windows cracked, the temperatures in a car on a warm day can become deadly in minutes.

 

Plant protein may protect against type 2 diabetes, meat eaters might be at greater risk

A new study from the University of Eastern Finland adds to the growing body of evidence indicating that the source of dietary protein may play a role in the risk of developing type 2 diabetes. The researchers found that plant protein was associated with a lower risk of type 2 diabetes, while persons with a diet rich in meat had a higher risk. The findings were published in the British Journal of Nutrition.

Earlier research has linked a high overall intake of protein and animal protein — and eating plenty of processed red meat in particular — with a higher risk of type 2 diabetes. However, the significance of proteins from different sources for the risk of diabetes is an understudied topic, prompting the researchers to analyse the associations of dietary protein with the risk of type 2 diabetes in the Kuopio Ischaemic Heart Disease Risk Factor Study, KIHD, carried out at the University of Eastern Finland. At the baseline of the study in 1984-1989, the researchers analysed the diets of 2,332 men who were between 42 and 60 years of age and who did not have type 2 diabetes at baseline. During a follow-up of 19 years, 432 men were diagnosed with type 2 diabetes.

Replacing animal protein with plant protein can reduce diabetes risk

Men with a high intake of plant protein also had healthy lifestyle habits, but lifestyle habits alone did not explain their lower risk of diabetes. The risk of men with the highest intake of plant protein to develop type 2 diabetes was 35 per cent smaller than the risk of those with the lowest intake of plant protein. Using a computational model, the researchers estimated that replacing approximately 5 grams of animal protein with plant protein daily would reduce the risk of diabetes by 18 per cent. The consumption of plant protein was also associated with lower blood glucose levels at the beginning of the study, which may explain the linkage of plant protein with reduced diabetes risk. In this study, grain products were the main source of plant protein, with other sources being potatoes and other vegetables.

The researchers also discovered an association of a high intake of meat with a higher risk of type 2 diabetes. The strongest association was seen in the consumption of meat in general, including processed and unprocessed red meat, white meat and variety meats. The link between eating meat and having a higher risk of diabetes is likely caused by other compounds found in meat than protein, as meat protein was not associated with the risk of diabetes. The intake of overall protein, animal protein, fish protein or dairy protein were not associated with the risk of type 2 diabetes. The association of egg protein was found to be similar to the research group’s earlier findings relating to the consumption of eggs: a higher intake was associated with a lower risk.

The findings indicate that a diet preferring plant protein may help prevent type 2 diabetes.

 

Artificial blood transfusions

Blood transfusions can save the lives of patients who have suffered major blood loss, but hospitals don’t always have enough or the right type on hand. In search of a solution, researchers have developed a promising substitute using blood’s oxygen-carrying component, hemoglobin. The in vitro study, reported in ACS’ journal Biomacromolecules, found that the modified hemoglobin was an effective oxygen carrier and also scavenged for potentially damaging free radicals.

Red blood cells are the most commonly transfused component of blood, according to the U.S. National Heart, Lung, and Blood Institute. These cells carry the protein hemoglobin, which performs the essential function of delivering oxygen to the body’s tissues. Scientists have tried developing chemically modified hemoglobin — which by itself is toxic — as a blood substitute but have found that it forms methemoglobin. This form of the protein doesn’t bind oxygen and thus decreases the amount of oxygen that blood delivers in the body. In addition, the generation of methemoglobin produces hydrogen peroxide, which leads to cell damage. Hong Zhou, Lian Zhao, Yan Wu and colleagues wanted to see if packaging hemoglobin in a benign envelope could get around these problems.

The researchers developed a one-step method for wrapping hemoglobin in polydopamine, or PDA, which has been widely studied for biomedical applications. A battery of lab tests showed that the PDA-coated hemoglobin effectively carried oxygen, while preventing the formation of methemoglobin and hydrogen peroxide. In addition, it caused minimal cell damage, and acted as an effective antioxidant, scavenging for potentially damaging free radicals and reactive oxygen species.

 

Past kidney injury may raise risk of poor pregnancy outcomes

The risk of preeclampsia and other pregnancy complications may be greater for expectant mothers who have a history of acute kidney injury, a new study finds, even when kidney function is normal prior to pregnancy.

Study leader Dr. Jessica Sheehan Tangren, of the Division of Nephrology at Massachusetts General Hospital (MGH) in Boston, and colleagues believe that their results indicate it is important for obstetricians to get a clear picture of past kidney health for pregnant women.

The researchers recently published their findings in the Journal of the American Society of Nephrology.

Acute kidney injury (AKI) is the sudden onset of kidney damage or failure. The condition can lead to an accumulation of waste products in the blood, an imbalance of body fluids, and it may also affect the function of other organs, including the brain, heart, and lungs.

According to the National Kidney Foundation, AKI is most common among older adults, but it can also affect children and young adults.

Causes of AKI include severe infections (such as sepsis), vasculitis (inflammation and scarring of the blood vessels), allergic reactions, low blood pressure, and major surgery.

Dr. Tangren and colleagues note that existing kidney disease is known to increase the risk of pregnancy complications for expectant mothers, but previous studies have not investigated how a history of AKI might impact pregnancy outcomes.

Preeclampsia risk 5.9 times greater with history of AKI

With the aim of finding out, the team analyzed the medical records of 24,745 women who gave birth at MGH between 1998-2007. Of these women, 24,640 had no history of kidney disease (the controls), while 105 had a history of AKI, from which they had fully recovered prior to pregnancy.

Compared with women who had no history of kidney disease, those with a history of recovered AKI (r-AKI) were found to be at much greater risk of pregnancy complications.

The rate of preeclampsia – a condition characterized by high blood pressure, swelling, and protein in the urine – was 4 percent for the controls, compared with 23 percent for women with a history of r-AKI.

Babies of women with a history of r-AKI were also more likely to be born earlier than those of the controls, at 37.6 weeks versus 39.2 weeks, respectively, and they were more likely to be born small for their gestational age, at 15 percent versus 8 percent, respectively.

Additionally, the team found that women with previous r-AKI were more likely to have a cesarean delivery than controls, at 40 percent versus 27 percent, respectively.

After adjusting for a number of possible confounding factors, the researchers found that women with a history of r-AKI were at 2.4 times greater risk of any adverse fetal outcome and 5.9 times increased risk of preeclampsia.

The researchers are unable to explain the mechanisms underlying the link between a history of r-AKI and greater risk of poor pregnancy outcomes. However, they say that it is possible for changes in small blood vessels that occur during kidney injury recovery to affect the kidney’s ability to function effectively during pregnancy.

“We know that kidneys undergo major changes during pregnancy, and that sort of ‘renal stress test’ may reveal previously undetected kidney disease in women with a history of acute kidney injury,” notes Dr. Tangren.

Findings highlight importance of past kidney health for pregnant women
While further studies are needed to confirm their findings, the researchers believe the current results indicate that expectant mothers with a history of AKI should be closely monitored throughout their pregnancy.

“Information like this helps obstetric providers know what to be vigilant for in pregnant women with a history of acute kidney injury and indicates that asking about such history is important,” notes study co-author Dr. Jeffrey Ecker, chief of obstetrics and gynecology at MGH.

“Being especially watchful for signs and symptoms of preeclampsia in such patients is one immediate application of this work,” he adds.

“In a longer view, work like this offers important hypotheses for future study. Can interventions in patients with a history of acute kidney injury prevent complications like preeclampsia?

Taking a baby aspirin each day during pregnancy is recommended for some women at high risk for preeclampsia. Should such preventive treatment be used in women with a history of acute kidney injury? Questions like this deserve further thought and study.”

Dr. Jeffrey Ecker

 

Daily Low-Dose Aspirin May Cut Pancreatic Cancer Risk

There’s evidence that daily low-dose aspirin may decrease the risk of pancreatic cancer, according to a new study.

The Chinese-based study couldn’t prove cause-and-effect. However, “the balance of evidence shows that people who use aspirin to reduce risk for cardiovascular disease or colorectal cancer can feel positive that their use likely also lowers their risk for pancreatic cancer,” said study lead author Dr. Harvey Risch.

He’s professor of epidemiology at the Yale School of Public Health and Yale Cancer Center in New Haven, Conn.

According to the American Cancer Society, about 53,000 Americans will be diagnosed with pancreatic cancer this year, and almost 42,000 will die from the disease. Pancreatic cancer is often a “silent killer” because symptoms do not emerge until the tumor is advanced.

The new study tracked 761 people diagnosed with pancreatic cancer in Shanghai from 2006 to 2011, and compared them to 794 people who didn’t have the cancer.

All the participants were asked about whether they took low-dose aspirin on a regular basis. Almost all who said they took it did so on a daily basis.

Eighteen percent of the non-cancer patients reported regular use of low-dose aspirin compared to 11 percent of the pancreatic cancer patients.

After adjusting their statistics so they wouldn’t be thrown off by various factors, the researchers estimate that aspirin may reduce the already small risk of pancreatic cancer by 46 percent.

However, Risch’s team stressed that the study doesn’t prove that aspirin directly produces a lower risk, and the participants may not have precisely remembered their aspirin intake.

An analysis of other studies found similar results. The researchers examined 18 other studies that had investigated aspirin use and pancreatic cancer risk over the past two decades and found that as aspirin use increased, the risk of pancreatic cancer significantly decreased.

“Pancreatic cancer is relatively rare — just 1.5 percent of U.S. adults will be diagnosed with it at some point during life — and regular aspirin use can cause appreciable complications for some,” Risch said in a news release from the American Association for Cancer Research. “Therefore, a person should consult his or her doctor about aspirin use.”

One oncologist who reviewed the data said Americans should be cautious in interpreting the results.

“This is an interesting study that suggests that regular aspirin use may reduce the incidence of pancreas cancer — in people living in China,” said Dr. Tony Philip, an oncologist at Northwell Health Cancer Institute in Lake Success, N.Y.

“Anything more than that cannot be extrapolated from this study,” he said. “We know the genetics of people in one part of the world is very different from other parts. In addition, we don’t know what else these patients were doing, for example, taking herbal medicine, their family history, or access to medical care.”

Philip said that he wouldn’t suggest daily low-dose aspirin to his patients based on this data alone. But the findings “can be the basis for further work” researching this issue, he added.

 

How nutritional guideline’s restriction on sugar intake is not based on high quality science

Nutritional guidelines restricting sugar intake are not based on high quality science, finds new study led by McMaster University and The Hospital for Sick Children (SickKids). The paper is published Dec. 19 in the Annals of Internal Medicine.

The research team conducted a systematic review of nine public health guidelines on sugar recommendations, including those by the influential U.S. Dietary Guidelines for Americans and the World Health Organization (WHO) and found that the recommendations for limiting sugar are based on low to very low quality evidence.

“Although our findings question the recommendations from guidelines produced by leading authorities, the findings should not be used to justify high or increased consumption of nutrient-poor, energy-dense foods and beverages like candy and sugar-sweetened beverages,” says Bradley Johnston, principal investigator of the review.

“We know that it is healthy and advisable to limit our sugar intake, the question remains to what degree, and if we are limiting our sugar intake what are we replacing the sugar with?”

Official caps on sugars vary widely, from less than five per cent of total daily calories, as recommended by the WHO, to advice from the Institute of Medicine which suggests the public to limit sugars to less than 25 per cent of total daily calories.

“When respected organizations issue conflicting recommendations it can result in public confusion, and this raises concerns about the quality of the guidelines, and the quality of the evidence that informed the guidelines,” says Johnston. He is an assistant professor in the Department of Clinical Epidemiology and Biostatistics at McMaster University; an assistant professor of health policy, management and evaluation at the University of Toronto; and scientist in Child Health Evaluative Sciences at SickKids.

Johnston uses former “low-fat” guidelines as an example: “For 40 years it was advised to eat a low fat diet and, as a result, the food industry and the public looked for ways to lower fat content in foods. What happened is that the fat was typically replaced by simple carbohydrates which included sugar creating a less than optimal outcome including an associated rise in obesity and diabetes.

“In the case of lowering sugar intake, what is happening is that sugars are often replaced with starches and other food additives like maltodextrine, providing the same calorie count, but often accompanied by an increased glycemic index (and blood glucose levels).”

The research team identified problems with the nutritional guidelines and in particular problems with the research that supported the guidelines’ recommendations such as; the inclusion of imprecise or small studies; a high risk of bias from uncontrolled studies; the use of outcome measures such as “nutrient displacement, tooth decay and limited weight gain” that are of lower priority to the public, compared to arguably more important outcomes such as obesity and diabetes; a lack of transparency regarding financial conflicts of interest among groups members who developed the guidelines, and a failure to include patient and public representatives in the panels drawing up the guidelines.

Co-first author, Behnam Sadeghirad, a McMaster PhD student in health research methodology, said “At present, there does not appear to be reliable evidence indicating that any of the recommended daily caloric thresholds for sugar intake are strongly associated with negative health effects. The results from this review should be used to promote improvement in the development of trustworthy guidelines on sugar intake.”