Children treated with complementary and alternative medicine (CAM) therapies were significantly less likely to receive the annual influenza vaccine than those who didn’t use alternative medicine, based on data from 9,000 children aged 4-17 years in the Child Complementary and Alternative Medicine File of the 2012 National Health Interview Survey.

“CAM has been implicated as lending support to antivaccine/vaccine-hesitant viewpoints via criticism of vaccination, public health, and conventional medicine from adults using CAM, as well as from CAM practitioners and practitioners-in-training,” wrote William K. Bleser, Ph.D., and his colleagues at Pennsylvania State University, University Park.

CAP53/iStockphoto.com

Children treated with complementary and alternative medicine (CAM) therapies were significantly less likely to receive the annual influenza vaccine than those who didn’t use alternative medicine, based on data from 9,000 children aged 4-17 years in the Child Complementary and Alternative Medicine File of the 2012 National Health Interview Survey.

“CAM has been implicated as lending support to antivaccine/vaccine-hesitant viewpoints via criticism of vaccination, public health, and conventional medicine from adults using CAM, as well as from CAM practitioners and practitioners-in-training,” wrote William K. Bleser, Ph.D., and his colleagues at Pennsylvania State University, University Park.

CAP53/iStockphoto.com

Children treated with complementary and alternative medicine (CAM) therapies were significantly less likely to receive the annual influenza vaccine than those who didn’t use alternative medicine, based on data from 9,000 children aged 4-17 years in the Child Complementary and Alternative Medicine File of the 2012 National Health Interview Survey.

“CAM has been implicated as lending support to antivaccine/vaccine-hesitant viewpoints via criticism of vaccination, public health, and conventional medicine from adults using CAM, as well as from CAM practitioners and practitioners-in-training,” wrote William K. Bleser, Ph.D., and his colleagues at Pennsylvania State University, University Park.

CAP53/iStockphoto.com

When my youngest daughter returns home from acting or dancing rehearsals, she talks about “notes” that she or the company received that day. Discussing them with her, I appreciate that giving notes to performers after rehearsal or even after a show is standard theater practice. The notes may be from the assistant stage director commenting on lines that were missed, mangled, or perfected. They also could be from the director concerning stage position or behaviors, or they may be about character development or a clarification about the emotions in a particular scene. They are written out as specific references to a certain line or segment of the script. Some directors write them on sticky memos so that they can actually be added to the actor’s script. Others keep their notes on index cards that can be sorted and handed out to the designated performer. My daughter works hard during the first part of the rehearsal process to get as few notes as possible, but at the end of the rehearsal process or during the run of the show, she likes getting notes as a reflection of how she is being perceived and to facilitate fine-tuning her performance.

Giving written notes in our offices to our colleagues, trainees, and staff after a day’s work is not likely to be productive; however, there are parts of this process that dermatologists can utilize. The notes give feedback that is timely and specific. They can be given to individuals or to the entire troupe. I also noticed that my daughter appeared to have a positive relationship with the note givers and looked for their feedback to improve her performance. When residents are on a procedural rotation with me, I endeavor to give them feedback every day about some part of their surgical technique to help them finesse their skills. I am not, however, as rigorous about giving feedback concerning other aspects of the practice, and so this editorial serves the purpose of reminding me that giving feedback is an important skill that we can and should use on a daily basis.

There are many guides for giving feedback. The Center for Creative Leadership developed a feedback technique called Situation-Behavior-Impact (S-B-I).¹ Similar to performance notes, it is simple, direct, and timely. Step 1: Capture the situation (S). Step 2: Describe the behavior (B). Step 3: Deliver the impact (I). For example, I have given the following feedback to many fellows when they are working with the resident: (S) “This morning when you two were finishing the repair, (B) you were talking about the lack of efficiency of the clinic in another hospital. (I) It made me uncomfortable because I believe the patient is the center of attention, and yet this was not a conversation that included him. I also worried that he would become nervous or anxious to hear about problems in a medical facility.” Another conversation could go: (S) “This morning with the patient with the eyelid tumor, (B) you told the patient that you would send the eye surgeon a photo so she could be prepared for the repair, and (I) I noticed the patient’s hands immediately relaxed.”

These are straightforward examples. There are more complicated situations that seem to require longer analysis; however, if we acquire the habit of immediate and specific feedback, there will be less need for more difficult conversations. Situation-Behavior-Impact is about behavior; it is not judgmental of the person, and it leaves room for the recipient to think about what happened without being defensive and to take action to create productive behaviors and improve performance. The Center for Creative Leadership recommends that feedback be framed as an observation, which further diminishes the development of a defensive rejection of the information.¹

Feedback is such an important loop for all of us professionally and personally because it is the mechanism that gives us the opportunity to improve our performance, so why don’t we always hear it in a constructive thought-provoking way? Stone and Heen² point out 3 triggers that escalate rejection of feedback: truth, relationship, and identity. They also can be described as immediate reactions: “You are wrong about your assessment,” “I don’t like you anyway,” and “You’re messing with who I am.” For those of you who want to up your game in any of your professional or personal arenas, Thanks for the Feedback: The Science and Art of Receiving Feedback Well² will open you up to seek out and take in feedback. Feedback-seeking behavior has been linked to higher job satisfaction, greater creativity on the job, and faster adaptation to change, while negative feedback has been linked to improved job performance.³ Interestingly, it also helps in our personal lives; a husband’s openness to influence and input from his spouse is a key predictor of marital health and stability^.4

In an effort to decrease resistance to hearing feedback, there are proponents of the sandwich technique in which a positive comment is made, then the negative feedback is given, followed by another positive comment. In my experience, this technique does not work. First, you have to give some thought to the appropriate items to bring to the discussion, so the conversation might be delayed long enough to obscure the memory of the details involved in the situations. Second, if you employ it often, the receiver tenses up with the first positive comment, knowing a negative comment will ensue, and so he/she is primed to reject the feedback before it is even offered. Finally, it confuses the priorities for the conversation. However, working over time to give more positive feedback than negative feedback (an average of 4–5 to 1) allows for the development of trust and mutual respect and quiets the urge to immediately reject the negative messages. In my experience, positive feedback is especially effective in creating engagement as well as validating and promoting desirable behaviors. Physicians may have to work deliberately to offer positive feedback because it is more natural for us to diagnose problems than to identify good health.

What impresses me most about the theater culture surrounding notes is that giving and receiving feedback is an expected element of the artistic process. As practitioners, wouldn’t we as well as our patients benefit if the culture of medicine also expected that we were giving each other feedback on a daily basis?

When my youngest daughter returns home from acting or dancing rehearsals, she talks about “notes” that she or the company received that day. Discussing them with her, I appreciate that giving notes to performers after rehearsal or even after a show is standard theater practice. The notes may be from the assistant stage director commenting on lines that were missed, mangled, or perfected. They also could be from the director concerning stage position or behaviors, or they may be about character development or a clarification about the emotions in a particular scene. They are written out as specific references to a certain line or segment of the script. Some directors write them on sticky memos so that they can actually be added to the actor’s script. Others keep their notes on index cards that can be sorted and handed out to the designated performer. My daughter works hard during the first part of the rehearsal process to get as few notes as possible, but at the end of the rehearsal process or during the run of the show, she likes getting notes as a reflection of how she is being perceived and to facilitate fine-tuning her performance.

Giving written notes in our offices to our colleagues, trainees, and staff after a day’s work is not likely to be productive; however, there are parts of this process that dermatologists can utilize. The notes give feedback that is timely and specific. They can be given to individuals or to the entire troupe. I also noticed that my daughter appeared to have a positive relationship with the note givers and looked for their feedback to improve her performance. When residents are on a procedural rotation with me, I endeavor to give them feedback every day about some part of their surgical technique to help them finesse their skills. I am not, however, as rigorous about giving feedback concerning other aspects of the practice, and so this editorial serves the purpose of reminding me that giving feedback is an important skill that we can and should use on a daily basis.

There are many guides for giving feedback. The Center for Creative Leadership developed a feedback technique called Situation-Behavior-Impact (S-B-I).¹ Similar to performance notes, it is simple, direct, and timely. Step 1: Capture the situation (S). Step 2: Describe the behavior (B). Step 3: Deliver the impact (I). For example, I have given the following feedback to many fellows when they are working with the resident: (S) “This morning when you two were finishing the repair, (B) you were talking about the lack of efficiency of the clinic in another hospital. (I) It made me uncomfortable because I believe the patient is the center of attention, and yet this was not a conversation that included him. I also worried that he would become nervous or anxious to hear about problems in a medical facility.” Another conversation could go: (S) “This morning with the patient with the eyelid tumor, (B) you told the patient that you would send the eye surgeon a photo so she could be prepared for the repair, and (I) I noticed the patient’s hands immediately relaxed.”

These are straightforward examples. There are more complicated situations that seem to require longer analysis; however, if we acquire the habit of immediate and specific feedback, there will be less need for more difficult conversations. Situation-Behavior-Impact is about behavior; it is not judgmental of the person, and it leaves room for the recipient to think about what happened without being defensive and to take action to create productive behaviors and improve performance. The Center for Creative Leadership recommends that feedback be framed as an observation, which further diminishes the development of a defensive rejection of the information.¹

Feedback is such an important loop for all of us professionally and personally because it is the mechanism that gives us the opportunity to improve our performance, so why don’t we always hear it in a constructive thought-provoking way? Stone and Heen² point out 3 triggers that escalate rejection of feedback: truth, relationship, and identity. They also can be described as immediate reactions: “You are wrong about your assessment,” “I don’t like you anyway,” and “You’re messing with who I am.” For those of you who want to up your game in any of your professional or personal arenas, Thanks for the Feedback: The Science and Art of Receiving Feedback Well² will open you up to seek out and take in feedback. Feedback-seeking behavior has been linked to higher job satisfaction, greater creativity on the job, and faster adaptation to change, while negative feedback has been linked to improved job performance.³ Interestingly, it also helps in our personal lives; a husband’s openness to influence and input from his spouse is a key predictor of marital health and stability^.4

In an effort to decrease resistance to hearing feedback, there are proponents of the sandwich technique in which a positive comment is made, then the negative feedback is given, followed by another positive comment. In my experience, this technique does not work. First, you have to give some thought to the appropriate items to bring to the discussion, so the conversation might be delayed long enough to obscure the memory of the details involved in the situations. Second, if you employ it often, the receiver tenses up with the first positive comment, knowing a negative comment will ensue, and so he/she is primed to reject the feedback before it is even offered. Finally, it confuses the priorities for the conversation. However, working over time to give more positive feedback than negative feedback (an average of 4–5 to 1) allows for the development of trust and mutual respect and quiets the urge to immediately reject the negative messages. In my experience, positive feedback is especially effective in creating engagement as well as validating and promoting desirable behaviors. Physicians may have to work deliberately to offer positive feedback because it is more natural for us to diagnose problems than to identify good health.

What impresses me most about the theater culture surrounding notes is that giving and receiving feedback is an expected element of the artistic process. As practitioners, wouldn’t we as well as our patients benefit if the culture of medicine also expected that we were giving each other feedback on a daily basis?

When my youngest daughter returns home from acting or dancing rehearsals, she talks about “notes” that she or the company received that day. Discussing them with her, I appreciate that giving notes to performers after rehearsal or even after a show is standard theater practice. The notes may be from the assistant stage director commenting on lines that were missed, mangled, or perfected. They also could be from the director concerning stage position or behaviors, or they may be about character development or a clarification about the emotions in a particular scene. They are written out as specific references to a certain line or segment of the script. Some directors write them on sticky memos so that they can actually be added to the actor’s script. Others keep their notes on index cards that can be sorted and handed out to the designated performer. My daughter works hard during the first part of the rehearsal process to get as few notes as possible, but at the end of the rehearsal process or during the run of the show, she likes getting notes as a reflection of how she is being perceived and to facilitate fine-tuning her performance.

Giving written notes in our offices to our colleagues, trainees, and staff after a day’s work is not likely to be productive; however, there are parts of this process that dermatologists can utilize. The notes give feedback that is timely and specific. They can be given to individuals or to the entire troupe. I also noticed that my daughter appeared to have a positive relationship with the note givers and looked for their feedback to improve her performance. When residents are on a procedural rotation with me, I endeavor to give them feedback every day about some part of their surgical technique to help them finesse their skills. I am not, however, as rigorous about giving feedback concerning other aspects of the practice, and so this editorial serves the purpose of reminding me that giving feedback is an important skill that we can and should use on a daily basis.

There are many guides for giving feedback. The Center for Creative Leadership developed a feedback technique called Situation-Behavior-Impact (S-B-I).¹ Similar to performance notes, it is simple, direct, and timely. Step 1: Capture the situation (S). Step 2: Describe the behavior (B). Step 3: Deliver the impact (I). For example, I have given the following feedback to many fellows when they are working with the resident: (S) “This morning when you two were finishing the repair, (B) you were talking about the lack of efficiency of the clinic in another hospital. (I) It made me uncomfortable because I believe the patient is the center of attention, and yet this was not a conversation that included him. I also worried that he would become nervous or anxious to hear about problems in a medical facility.” Another conversation could go: (S) “This morning with the patient with the eyelid tumor, (B) you told the patient that you would send the eye surgeon a photo so she could be prepared for the repair, and (I) I noticed the patient’s hands immediately relaxed.”

These are straightforward examples. There are more complicated situations that seem to require longer analysis; however, if we acquire the habit of immediate and specific feedback, there will be less need for more difficult conversations. Situation-Behavior-Impact is about behavior; it is not judgmental of the person, and it leaves room for the recipient to think about what happened without being defensive and to take action to create productive behaviors and improve performance. The Center for Creative Leadership recommends that feedback be framed as an observation, which further diminishes the development of a defensive rejection of the information.¹

Feedback is such an important loop for all of us professionally and personally because it is the mechanism that gives us the opportunity to improve our performance, so why don’t we always hear it in a constructive thought-provoking way? Stone and Heen² point out 3 triggers that escalate rejection of feedback: truth, relationship, and identity. They also can be described as immediate reactions: “You are wrong about your assessment,” “I don’t like you anyway,” and “You’re messing with who I am.” For those of you who want to up your game in any of your professional or personal arenas, Thanks for the Feedback: The Science and Art of Receiving Feedback Well² will open you up to seek out and take in feedback. Feedback-seeking behavior has been linked to higher job satisfaction, greater creativity on the job, and faster adaptation to change, while negative feedback has been linked to improved job performance.³ Interestingly, it also helps in our personal lives; a husband’s openness to influence and input from his spouse is a key predictor of marital health and stability^.4

In an effort to decrease resistance to hearing feedback, there are proponents of the sandwich technique in which a positive comment is made, then the negative feedback is given, followed by another positive comment. In my experience, this technique does not work. First, you have to give some thought to the appropriate items to bring to the discussion, so the conversation might be delayed long enough to obscure the memory of the details involved in the situations. Second, if you employ it often, the receiver tenses up with the first positive comment, knowing a negative comment will ensue, and so he/she is primed to reject the feedback before it is even offered. Finally, it confuses the priorities for the conversation. However, working over time to give more positive feedback than negative feedback (an average of 4–5 to 1) allows for the development of trust and mutual respect and quiets the urge to immediately reject the negative messages. In my experience, positive feedback is especially effective in creating engagement as well as validating and promoting desirable behaviors. Physicians may have to work deliberately to offer positive feedback because it is more natural for us to diagnose problems than to identify good health.

What impresses me most about the theater culture surrounding notes is that giving and receiving feedback is an expected element of the artistic process. As practitioners, wouldn’t we as well as our patients benefit if the culture of medicine also expected that we were giving each other feedback on a daily basis?

Physical activity is a key determinant of health. Low levels of activity are associated with onset of and poorer outcomes of many chronic health conditions (eg, obesity, coronary artery disease, type 2 diabetes mellitus, chronic pain, hypertension^1-4) and with higher rates of mental health conditions (eg, depression, anxiety^5-8).

Behavioral interventions (Table 1) can increase activity and improve physical health and mental health (Table 2).^9-21 However, only 20% of adults in the U.S. meet federal recommendations for physical activity.²² The situation is particularly grim in the veteran population. Littman and colleagues found that veterans were less likely than nonveterans were to meet physical activity standards, and VA patients were even less likely than were non-VA veterans to meet the recommendations.²³

Given that exercise can positively affect physical and mental health and that VA mental health care professionals (MHCPs) have training in motivational enhancement and behavior modification, these clinicians are well positioned to intervene. The question arises, though: How can VA MHCPs do more to effectively promote physical activity in veterans?

Addressing Physical Activity

There are numerous ways in which VA MHCPs can address physical activity with their patients. Several studies have demonstrated that physical activity interventions provided within primary care–mental health integration programs resulted in increased physical activity.^28,29 The number of VA health care providers (HCPs) offering such programs is increasing, which could mean that behavioral health support for physical activity promotion could become easier for veterans to access.³⁰

In addition, National Center for Health Promotion and Disease Prevention initiatives have led to an expansion of programs, such as the VA MOVE! Weight Management Program.³¹ Often cofacilitated by dieticians and MHCPs, MOVE! includes nutrition education, behavior modification, and physical activity promotion.³² Preliminary research suggests that MOVE! helps veterans lose weight and improve their health-related quality of life.^33-36

Further, psychological and behavioral interventions can specifically target exercise and have been shown to increase physical activity, improve mood symptoms, and reduce health risk factors.^9-21,37 However, little is known about the extent of exercise promotion in VA outpatient mental health services. For instance, some HCPs may educate patients about the benefits of physical activity, while others may facilitate physical activity scheduling, address barriers, and monitor, reinforce, and problem-solve physical activity goals.

Research also has supported the efficacy of technology-based interventions in physical activity promotion by MHCPs. These interventions include phone counseling, text messaging or smartphone application monitoring systems (including the MOVE! Coach mobile app), DVD-based approaches, and web-based interventions.^38-42 However, these interventions may be most effective when complemented with face-to-face support (eg, psychotherapy, nutrition/exercise classes).⁴³ Although MHCPs can promote physical activity in various ways, intensive focus on this target is not standard practice in many mental health care settings.

Barriers to Physical Activity

Despite physical activity promotion efforts, patients struggle to implement and maintain physical activity recommendations.^22,44,45 For many patients, exercise is a new or long abandoned activity, and instruction on how to exercise properly is needed.⁴⁶ Lack of financial resources may limit access to a gym, trainer, or physical therapist.⁴⁷ Some patients avoid exercise because of body image concerns, and many think they lack the self-discipline and time for exercise.^46,48,49

Additional barriers to physical activity are pain, fatigue, and other physical symptoms.^50-52 Obese patients may find physical activity less enjoyable and more uncomfortable.⁵³ Some patients fear exercise will exacerbate medical problems or have negative physical consequences.^51,52

Psychiatric symptoms and medication adverse effects are commonly reported barriers.⁵⁴ Some patients with anxiety avoid physical activity because the resulting physiologic sensations (eg, rapid heart rate, sweating) are similar to anxiety symptoms.⁵⁵ Patients with posttraumatic stress disorder (PTSD) are less likely to exercise, secondary to PTSD-related avoidance, even though they were physically active before their trauma.^56-58 Some patients with depression avoid exercise and other activities because their symptoms (eg, fatigue, anhedonia) make it difficult for them to take action. Many patients put off exercise while waiting for relief of mental health symptoms, even though evidence suggests that physical activity may help improve those symptoms.^5,6

These barriers often render ineffective the approach of simply recommending exercise or encouraging patients to exercise. Counseling alone may not be sufficient to effect meaningful change in exercise habits. Many effective physical activity interventions have both a counseling and exercise components,^59-61 and research suggests that such interventions may be most effective when they include a form of experiential exercise.¹⁰

Clinician-Assisted Experiential Exercise

Exercise interventions may involve information dissemination, counseling, an experiential exercise program, or a combination of these activities. Research has yet to determine precisely which components are most effective. Given the barriers to adhering to exercise recommendations, however, exercise interventions that include an experiential component may be more likely to affect behavior change.

According to Sime, exercise therapy is the “practice of combining a program of exercise with traditional psychotherapy.”⁶² Sime outlined a 10-session approach to exercise therapy and suggested that walking with patients while engaging in psychotherapy can reduce barriers to change. This approach may be effective for several reasons. First, it models the recommendation to engage in activity despite not feeling well and often improves mood. Second, the experiential nature of the intervention gives the patient an immediate opportunity to physically feel the benefits of activity. Third, the experiential component is similar to experiential exercise interventions, which have been shown to improve chronic health problems, such as obesity, and it parallels in vivo exposure, which is highly effective in treating anxiety.^10,63

Exposure to exercise also has been effective in treating chronic pain in patients who fear physical activity because they anticipate pain or reinjury. In patients with chronic low back pain, in vivo exposure reduced anxiety more than an education-only session did, and the result was improved participation in relevant daily activities.⁶⁴ Results were sustained at the 6-month follow-up but only for patients who received in vivo exposure.⁶⁵ Similarly, in vivo exposure to feared movements increased physical activity and reduced pain-related fear, catastrophizing, and disability in patients with chronic low back pain.⁶⁵ These findings have implications for other chronic health problems. Particularly for patients who fear and avoid exercise, psychoeducation about exercise and opportunities to experience exercise in session may increase physical activity outside of therapy.¹⁰

Obstacles to Exercise Promotion

Mental health care providers may be reluctant to use experiential exercise interventions for a variety of reasons. Some fear that they or their patients might sustain an injury or an exacerbation of physical symptoms. In addition, some MHCPs have liability and safety concerns surrounding meetings with patients outside the office. And obtaining medical clearance requires extra time and energy.

Some MHCPs think that this type of experiential activity might cross a professional boundary. Others may wonder whether providing experiential exercise as part of mental health services is sufficiently evidence based or is a breach of standards of practice. Similarly, some MHCPs who use manual-based interventions are hesitant to stray from an evidence-based protocol and include experiential exercise in psychotherapy. Further, some MHCPs do not feel competent to provide such an intervention, given that it is not typically covered in their mental health care training, and they think that providing opportunities for experiential exercise falls outside their MHCP role. Last, some MHCPs are uncomfortable exercising on their own and thus may be particularly uncomfortable exercising in front of patients.

Promoting Physical Activity

Although significant, barriers to promotion of physical activity can be effectively reduced by taking the steps outlined in Table 3. First, MHCPs must reflect on their own past and present physical activity and on their readiness to provide clinician-assisted experiential exercise. In addition, MHCPs should explore nearby alternative resources for physical activity, share their findings with patients, and encourage patients to use these resources. Next, medical clearance for increased physical activity can be obtained from patients’ primary care physicians, and any physical activity recommendations or limitations can be reviewed and documented. Mental health care providers should then obtain patients’ informed consent, which involves discussing the potential risks and benefits of increased exercise and, if appropriate, collaborate with patients to reach an agreement to focus on physical activity as an important aspect of their work together. Any additional risks and benefits of clinician-assisted experiential exercise can be discussed, and the ways in which physical activity can be used in session (eg, “walk and talk therapy”; other exercises recommended by the medical team) can be reviewed. Further, MHCPs can clarify their role and discuss how clear boundaries will be maintained within the therapeutic relationship. Alternative VA and community services that can help increase physical activity should also be discussed.

Once these steps are complete, MHCPs can address patient’s barriers to physical activity (Table 4). A discussion of the patient’s physical activity history is a good starting point. Biopsychosocial factors that can affect the ability to engage in and follow through with physical activity can then be explored, and HCPs and patients can set specific attainable physical activity goals. For instance, MHCPs can specify whether in-session clinic-assisted experiential exercise will be used and, if so, in what capacity. Last, physical activity goals can be revised periodically and revisited with the medical team.

Alternate Promotions

Mental health care providers also should consider involving other HCPs. Physical therapists and exercise physiologists are in a unique position to provide experiential exercise training. Some VA facilities include experiential exercise in their MOVE! program—veterans exercise together in the VA’s physical therapy gym while being monitored by a physical therapist.

Peer support specialists (PSPs) also are in a unique position to effectively provide experiential physical activity interventions at VA facilities. These PSPs are veterans who have physical or mental health problems but are far enough along in recovery to provide helpful services to other veterans with similar challenges.⁶⁶ Recent organizational efforts have increased the presence of PSPs in VA clinics. Peer support specialists use aspects of their recovery to help other veterans, provide supportive counseling, and facilitate activity groups, such as walking, hiking, golfing, and photography groups. Further, PSPs may not have to deal with MHCPs’ concerns regarding scope of practice and clinical boundaries vis-à-vis exercise interventions.

Other VA and community programs provide ways for veterans to engage in experiential physical activities. Some VA facilities have pools and gyms that provide open hours for veterans; some even offer free HCP guidance. Clinics also occasionally provide transportation to community gyms that offer veterans discounted memberships. Team Red, White, and Blue (https://www.teamrwb.org), Veterans Expeditions, (http://www.vetexpeditions.com) and other community organizations promote veterans’ physical activity by organizing events, such as endurance races, fly fishing, and mountaineering. By staying up-to-date on local community services, MHCPs can facilitate opportunities for experiential exercise alongside the psychotherapy services they provide.

Although valuable resources exist, veterans nevertheless encounter obstacles to exercise. For instance, many VA HCPs do not include physical therapy as a standard part of the MOVE! program. Others offer physical therapy not as an integrated service but as a separate, optional service, and attendance requires more initiative. Often, veterans are referred for physical therapy only if they have sustained an injury. Even when physical therapy or exercise physiology services are offered, many veterans have difficulty following through. Reasons include anxiety, time constraints, difficulty managing multiple appointments, and negative beliefs about exercise and physical therapy (eg, it will make me hurt, physical therapy is only for people recovering from an injury). Last, some veterans are reluctant to engage in peer-led or non-VA exercise programs.

Future Research

This article highlights the need for research in several areas. First, it would be helpful to know the extent to which VA MHCPs are already promoting physical activity for their patients and the ways in which they are using experiential exercise interventions. Research also will help determine the extent to which experiential exercise interventions can be effective in treating mental and physical health conditions not listed in Table 2 and any conditions for which exercise interventions may be contraindicated. The effectiveness of exercise therapy, as described by Sime, also warrants more investigation with randomized clinical trials.⁶² Further, it would be useful to know more about the extent and effectiveness of other experiential exercise available to veterans, whether through the MOVE! program or through other VA or community resources. This would help HCPs understand how to best promote physical activity in veterans with chronic physical and mental health needs.

Conclusion

Most people fall short of recommended levels of physical activity, and this is especially true of veterans, who also are at higher risk for chronic physical and mental health problems.^23,24 VA MHCPs are in a unique position to promote physical activity, and therapy programs that include experiential exercise may be particularly effective in helping veterans become and stay active. Other providers are well suited to provide experiential exercise opportunities, but MHCPs can simultaneously address the psychological factors that prevent veterans from engaging in exercise. Although VA MHCPs should continue to collaborate with other resources that can provide experiential exercise, they should also consider the potential benefit of experiential exercise within psychotherapy.

Physical activity is a key determinant of health. Low levels of activity are associated with onset of and poorer outcomes of many chronic health conditions (eg, obesity, coronary artery disease, type 2 diabetes mellitus, chronic pain, hypertension^1-4) and with higher rates of mental health conditions (eg, depression, anxiety^5-8).

Behavioral interventions (Table 1) can increase activity and improve physical health and mental health (Table 2).^9-21 However, only 20% of adults in the U.S. meet federal recommendations for physical activity.²² The situation is particularly grim in the veteran population. Littman and colleagues found that veterans were less likely than nonveterans were to meet physical activity standards, and VA patients were even less likely than were non-VA veterans to meet the recommendations.²³

Given that exercise can positively affect physical and mental health and that VA mental health care professionals (MHCPs) have training in motivational enhancement and behavior modification, these clinicians are well positioned to intervene. The question arises, though: How can VA MHCPs do more to effectively promote physical activity in veterans?

Addressing Physical Activity

There are numerous ways in which VA MHCPs can address physical activity with their patients. Several studies have demonstrated that physical activity interventions provided within primary care–mental health integration programs resulted in increased physical activity.^28,29 The number of VA health care providers (HCPs) offering such programs is increasing, which could mean that behavioral health support for physical activity promotion could become easier for veterans to access.³⁰

In addition, National Center for Health Promotion and Disease Prevention initiatives have led to an expansion of programs, such as the VA MOVE! Weight Management Program.³¹ Often cofacilitated by dieticians and MHCPs, MOVE! includes nutrition education, behavior modification, and physical activity promotion.³² Preliminary research suggests that MOVE! helps veterans lose weight and improve their health-related quality of life.^33-36

Further, psychological and behavioral interventions can specifically target exercise and have been shown to increase physical activity, improve mood symptoms, and reduce health risk factors.^9-21,37 However, little is known about the extent of exercise promotion in VA outpatient mental health services. For instance, some HCPs may educate patients about the benefits of physical activity, while others may facilitate physical activity scheduling, address barriers, and monitor, reinforce, and problem-solve physical activity goals.

Research also has supported the efficacy of technology-based interventions in physical activity promotion by MHCPs. These interventions include phone counseling, text messaging or smartphone application monitoring systems (including the MOVE! Coach mobile app), DVD-based approaches, and web-based interventions.^38-42 However, these interventions may be most effective when complemented with face-to-face support (eg, psychotherapy, nutrition/exercise classes).⁴³ Although MHCPs can promote physical activity in various ways, intensive focus on this target is not standard practice in many mental health care settings.

Barriers to Physical Activity

Despite physical activity promotion efforts, patients struggle to implement and maintain physical activity recommendations.^22,44,45 For many patients, exercise is a new or long abandoned activity, and instruction on how to exercise properly is needed.⁴⁶ Lack of financial resources may limit access to a gym, trainer, or physical therapist.⁴⁷ Some patients avoid exercise because of body image concerns, and many think they lack the self-discipline and time for exercise.^46,48,49

Additional barriers to physical activity are pain, fatigue, and other physical symptoms.^50-52 Obese patients may find physical activity less enjoyable and more uncomfortable.⁵³ Some patients fear exercise will exacerbate medical problems or have negative physical consequences.^51,52

Psychiatric symptoms and medication adverse effects are commonly reported barriers.⁵⁴ Some patients with anxiety avoid physical activity because the resulting physiologic sensations (eg, rapid heart rate, sweating) are similar to anxiety symptoms.⁵⁵ Patients with posttraumatic stress disorder (PTSD) are less likely to exercise, secondary to PTSD-related avoidance, even though they were physically active before their trauma.^56-58 Some patients with depression avoid exercise and other activities because their symptoms (eg, fatigue, anhedonia) make it difficult for them to take action. Many patients put off exercise while waiting for relief of mental health symptoms, even though evidence suggests that physical activity may help improve those symptoms.^5,6

These barriers often render ineffective the approach of simply recommending exercise or encouraging patients to exercise. Counseling alone may not be sufficient to effect meaningful change in exercise habits. Many effective physical activity interventions have both a counseling and exercise components,^59-61 and research suggests that such interventions may be most effective when they include a form of experiential exercise.¹⁰

Clinician-Assisted Experiential Exercise

Exercise interventions may involve information dissemination, counseling, an experiential exercise program, or a combination of these activities. Research has yet to determine precisely which components are most effective. Given the barriers to adhering to exercise recommendations, however, exercise interventions that include an experiential component may be more likely to affect behavior change.

According to Sime, exercise therapy is the “practice of combining a program of exercise with traditional psychotherapy.”⁶² Sime outlined a 10-session approach to exercise therapy and suggested that walking with patients while engaging in psychotherapy can reduce barriers to change. This approach may be effective for several reasons. First, it models the recommendation to engage in activity despite not feeling well and often improves mood. Second, the experiential nature of the intervention gives the patient an immediate opportunity to physically feel the benefits of activity. Third, the experiential component is similar to experiential exercise interventions, which have been shown to improve chronic health problems, such as obesity, and it parallels in vivo exposure, which is highly effective in treating anxiety.^10,63

Exposure to exercise also has been effective in treating chronic pain in patients who fear physical activity because they anticipate pain or reinjury. In patients with chronic low back pain, in vivo exposure reduced anxiety more than an education-only session did, and the result was improved participation in relevant daily activities.⁶⁴ Results were sustained at the 6-month follow-up but only for patients who received in vivo exposure.⁶⁵ Similarly, in vivo exposure to feared movements increased physical activity and reduced pain-related fear, catastrophizing, and disability in patients with chronic low back pain.⁶⁵ These findings have implications for other chronic health problems. Particularly for patients who fear and avoid exercise, psychoeducation about exercise and opportunities to experience exercise in session may increase physical activity outside of therapy.¹⁰

Obstacles to Exercise Promotion

Mental health care providers may be reluctant to use experiential exercise interventions for a variety of reasons. Some fear that they or their patients might sustain an injury or an exacerbation of physical symptoms. In addition, some MHCPs have liability and safety concerns surrounding meetings with patients outside the office. And obtaining medical clearance requires extra time and energy.

Some MHCPs think that this type of experiential activity might cross a professional boundary. Others may wonder whether providing experiential exercise as part of mental health services is sufficiently evidence based or is a breach of standards of practice. Similarly, some MHCPs who use manual-based interventions are hesitant to stray from an evidence-based protocol and include experiential exercise in psychotherapy. Further, some MHCPs do not feel competent to provide such an intervention, given that it is not typically covered in their mental health care training, and they think that providing opportunities for experiential exercise falls outside their MHCP role. Last, some MHCPs are uncomfortable exercising on their own and thus may be particularly uncomfortable exercising in front of patients.

Promoting Physical Activity

Although significant, barriers to promotion of physical activity can be effectively reduced by taking the steps outlined in Table 3. First, MHCPs must reflect on their own past and present physical activity and on their readiness to provide clinician-assisted experiential exercise. In addition, MHCPs should explore nearby alternative resources for physical activity, share their findings with patients, and encourage patients to use these resources. Next, medical clearance for increased physical activity can be obtained from patients’ primary care physicians, and any physical activity recommendations or limitations can be reviewed and documented. Mental health care providers should then obtain patients’ informed consent, which involves discussing the potential risks and benefits of increased exercise and, if appropriate, collaborate with patients to reach an agreement to focus on physical activity as an important aspect of their work together. Any additional risks and benefits of clinician-assisted experiential exercise can be discussed, and the ways in which physical activity can be used in session (eg, “walk and talk therapy”; other exercises recommended by the medical team) can be reviewed. Further, MHCPs can clarify their role and discuss how clear boundaries will be maintained within the therapeutic relationship. Alternative VA and community services that can help increase physical activity should also be discussed.

Once these steps are complete, MHCPs can address patient’s barriers to physical activity (Table 4). A discussion of the patient’s physical activity history is a good starting point. Biopsychosocial factors that can affect the ability to engage in and follow through with physical activity can then be explored, and HCPs and patients can set specific attainable physical activity goals. For instance, MHCPs can specify whether in-session clinic-assisted experiential exercise will be used and, if so, in what capacity. Last, physical activity goals can be revised periodically and revisited with the medical team.

Alternate Promotions

Mental health care providers also should consider involving other HCPs. Physical therapists and exercise physiologists are in a unique position to provide experiential exercise training. Some VA facilities include experiential exercise in their MOVE! program—veterans exercise together in the VA’s physical therapy gym while being monitored by a physical therapist.

Peer support specialists (PSPs) also are in a unique position to effectively provide experiential physical activity interventions at VA facilities. These PSPs are veterans who have physical or mental health problems but are far enough along in recovery to provide helpful services to other veterans with similar challenges.⁶⁶ Recent organizational efforts have increased the presence of PSPs in VA clinics. Peer support specialists use aspects of their recovery to help other veterans, provide supportive counseling, and facilitate activity groups, such as walking, hiking, golfing, and photography groups. Further, PSPs may not have to deal with MHCPs’ concerns regarding scope of practice and clinical boundaries vis-à-vis exercise interventions.

Other VA and community programs provide ways for veterans to engage in experiential physical activities. Some VA facilities have pools and gyms that provide open hours for veterans; some even offer free HCP guidance. Clinics also occasionally provide transportation to community gyms that offer veterans discounted memberships. Team Red, White, and Blue (https://www.teamrwb.org), Veterans Expeditions, (http://www.vetexpeditions.com) and other community organizations promote veterans’ physical activity by organizing events, such as endurance races, fly fishing, and mountaineering. By staying up-to-date on local community services, MHCPs can facilitate opportunities for experiential exercise alongside the psychotherapy services they provide.

Although valuable resources exist, veterans nevertheless encounter obstacles to exercise. For instance, many VA HCPs do not include physical therapy as a standard part of the MOVE! program. Others offer physical therapy not as an integrated service but as a separate, optional service, and attendance requires more initiative. Often, veterans are referred for physical therapy only if they have sustained an injury. Even when physical therapy or exercise physiology services are offered, many veterans have difficulty following through. Reasons include anxiety, time constraints, difficulty managing multiple appointments, and negative beliefs about exercise and physical therapy (eg, it will make me hurt, physical therapy is only for people recovering from an injury). Last, some veterans are reluctant to engage in peer-led or non-VA exercise programs.

Future Research

This article highlights the need for research in several areas. First, it would be helpful to know the extent to which VA MHCPs are already promoting physical activity for their patients and the ways in which they are using experiential exercise interventions. Research also will help determine the extent to which experiential exercise interventions can be effective in treating mental and physical health conditions not listed in Table 2 and any conditions for which exercise interventions may be contraindicated. The effectiveness of exercise therapy, as described by Sime, also warrants more investigation with randomized clinical trials.⁶² Further, it would be useful to know more about the extent and effectiveness of other experiential exercise available to veterans, whether through the MOVE! program or through other VA or community resources. This would help HCPs understand how to best promote physical activity in veterans with chronic physical and mental health needs.

Conclusion

Most people fall short of recommended levels of physical activity, and this is especially true of veterans, who also are at higher risk for chronic physical and mental health problems.^23,24 VA MHCPs are in a unique position to promote physical activity, and therapy programs that include experiential exercise may be particularly effective in helping veterans become and stay active. Other providers are well suited to provide experiential exercise opportunities, but MHCPs can simultaneously address the psychological factors that prevent veterans from engaging in exercise. Although VA MHCPs should continue to collaborate with other resources that can provide experiential exercise, they should also consider the potential benefit of experiential exercise within psychotherapy.

Physical activity is a key determinant of health. Low levels of activity are associated with onset of and poorer outcomes of many chronic health conditions (eg, obesity, coronary artery disease, type 2 diabetes mellitus, chronic pain, hypertension^1-4) and with higher rates of mental health conditions (eg, depression, anxiety^5-8).

Behavioral interventions (Table 1) can increase activity and improve physical health and mental health (Table 2).^9-21 However, only 20% of adults in the U.S. meet federal recommendations for physical activity.²² The situation is particularly grim in the veteran population. Littman and colleagues found that veterans were less likely than nonveterans were to meet physical activity standards, and VA patients were even less likely than were non-VA veterans to meet the recommendations.²³

Given that exercise can positively affect physical and mental health and that VA mental health care professionals (MHCPs) have training in motivational enhancement and behavior modification, these clinicians are well positioned to intervene. The question arises, though: How can VA MHCPs do more to effectively promote physical activity in veterans?

Addressing Physical Activity

There are numerous ways in which VA MHCPs can address physical activity with their patients. Several studies have demonstrated that physical activity interventions provided within primary care–mental health integration programs resulted in increased physical activity.^28,29 The number of VA health care providers (HCPs) offering such programs is increasing, which could mean that behavioral health support for physical activity promotion could become easier for veterans to access.³⁰

In addition, National Center for Health Promotion and Disease Prevention initiatives have led to an expansion of programs, such as the VA MOVE! Weight Management Program.³¹ Often cofacilitated by dieticians and MHCPs, MOVE! includes nutrition education, behavior modification, and physical activity promotion.³² Preliminary research suggests that MOVE! helps veterans lose weight and improve their health-related quality of life.^33-36

Further, psychological and behavioral interventions can specifically target exercise and have been shown to increase physical activity, improve mood symptoms, and reduce health risk factors.^9-21,37 However, little is known about the extent of exercise promotion in VA outpatient mental health services. For instance, some HCPs may educate patients about the benefits of physical activity, while others may facilitate physical activity scheduling, address barriers, and monitor, reinforce, and problem-solve physical activity goals.

Research also has supported the efficacy of technology-based interventions in physical activity promotion by MHCPs. These interventions include phone counseling, text messaging or smartphone application monitoring systems (including the MOVE! Coach mobile app), DVD-based approaches, and web-based interventions.^38-42 However, these interventions may be most effective when complemented with face-to-face support (eg, psychotherapy, nutrition/exercise classes).⁴³ Although MHCPs can promote physical activity in various ways, intensive focus on this target is not standard practice in many mental health care settings.

Barriers to Physical Activity

Despite physical activity promotion efforts, patients struggle to implement and maintain physical activity recommendations.^22,44,45 For many patients, exercise is a new or long abandoned activity, and instruction on how to exercise properly is needed.⁴⁶ Lack of financial resources may limit access to a gym, trainer, or physical therapist.⁴⁷ Some patients avoid exercise because of body image concerns, and many think they lack the self-discipline and time for exercise.^46,48,49

Additional barriers to physical activity are pain, fatigue, and other physical symptoms.^50-52 Obese patients may find physical activity less enjoyable and more uncomfortable.⁵³ Some patients fear exercise will exacerbate medical problems or have negative physical consequences.^51,52

Psychiatric symptoms and medication adverse effects are commonly reported barriers.⁵⁴ Some patients with anxiety avoid physical activity because the resulting physiologic sensations (eg, rapid heart rate, sweating) are similar to anxiety symptoms.⁵⁵ Patients with posttraumatic stress disorder (PTSD) are less likely to exercise, secondary to PTSD-related avoidance, even though they were physically active before their trauma.^56-58 Some patients with depression avoid exercise and other activities because their symptoms (eg, fatigue, anhedonia) make it difficult for them to take action. Many patients put off exercise while waiting for relief of mental health symptoms, even though evidence suggests that physical activity may help improve those symptoms.^5,6

These barriers often render ineffective the approach of simply recommending exercise or encouraging patients to exercise. Counseling alone may not be sufficient to effect meaningful change in exercise habits. Many effective physical activity interventions have both a counseling and exercise components,^59-61 and research suggests that such interventions may be most effective when they include a form of experiential exercise.¹⁰

Clinician-Assisted Experiential Exercise

Exercise interventions may involve information dissemination, counseling, an experiential exercise program, or a combination of these activities. Research has yet to determine precisely which components are most effective. Given the barriers to adhering to exercise recommendations, however, exercise interventions that include an experiential component may be more likely to affect behavior change.

According to Sime, exercise therapy is the “practice of combining a program of exercise with traditional psychotherapy.”⁶² Sime outlined a 10-session approach to exercise therapy and suggested that walking with patients while engaging in psychotherapy can reduce barriers to change. This approach may be effective for several reasons. First, it models the recommendation to engage in activity despite not feeling well and often improves mood. Second, the experiential nature of the intervention gives the patient an immediate opportunity to physically feel the benefits of activity. Third, the experiential component is similar to experiential exercise interventions, which have been shown to improve chronic health problems, such as obesity, and it parallels in vivo exposure, which is highly effective in treating anxiety.^10,63

Exposure to exercise also has been effective in treating chronic pain in patients who fear physical activity because they anticipate pain or reinjury. In patients with chronic low back pain, in vivo exposure reduced anxiety more than an education-only session did, and the result was improved participation in relevant daily activities.⁶⁴ Results were sustained at the 6-month follow-up but only for patients who received in vivo exposure.⁶⁵ Similarly, in vivo exposure to feared movements increased physical activity and reduced pain-related fear, catastrophizing, and disability in patients with chronic low back pain.⁶⁵ These findings have implications for other chronic health problems. Particularly for patients who fear and avoid exercise, psychoeducation about exercise and opportunities to experience exercise in session may increase physical activity outside of therapy.¹⁰

Obstacles to Exercise Promotion

Mental health care providers may be reluctant to use experiential exercise interventions for a variety of reasons. Some fear that they or their patients might sustain an injury or an exacerbation of physical symptoms. In addition, some MHCPs have liability and safety concerns surrounding meetings with patients outside the office. And obtaining medical clearance requires extra time and energy.

Some MHCPs think that this type of experiential activity might cross a professional boundary. Others may wonder whether providing experiential exercise as part of mental health services is sufficiently evidence based or is a breach of standards of practice. Similarly, some MHCPs who use manual-based interventions are hesitant to stray from an evidence-based protocol and include experiential exercise in psychotherapy. Further, some MHCPs do not feel competent to provide such an intervention, given that it is not typically covered in their mental health care training, and they think that providing opportunities for experiential exercise falls outside their MHCP role. Last, some MHCPs are uncomfortable exercising on their own and thus may be particularly uncomfortable exercising in front of patients.

Promoting Physical Activity

Although significant, barriers to promotion of physical activity can be effectively reduced by taking the steps outlined in Table 3. First, MHCPs must reflect on their own past and present physical activity and on their readiness to provide clinician-assisted experiential exercise. In addition, MHCPs should explore nearby alternative resources for physical activity, share their findings with patients, and encourage patients to use these resources. Next, medical clearance for increased physical activity can be obtained from patients’ primary care physicians, and any physical activity recommendations or limitations can be reviewed and documented. Mental health care providers should then obtain patients’ informed consent, which involves discussing the potential risks and benefits of increased exercise and, if appropriate, collaborate with patients to reach an agreement to focus on physical activity as an important aspect of their work together. Any additional risks and benefits of clinician-assisted experiential exercise can be discussed, and the ways in which physical activity can be used in session (eg, “walk and talk therapy”; other exercises recommended by the medical team) can be reviewed. Further, MHCPs can clarify their role and discuss how clear boundaries will be maintained within the therapeutic relationship. Alternative VA and community services that can help increase physical activity should also be discussed.

Once these steps are complete, MHCPs can address patient’s barriers to physical activity (Table 4). A discussion of the patient’s physical activity history is a good starting point. Biopsychosocial factors that can affect the ability to engage in and follow through with physical activity can then be explored, and HCPs and patients can set specific attainable physical activity goals. For instance, MHCPs can specify whether in-session clinic-assisted experiential exercise will be used and, if so, in what capacity. Last, physical activity goals can be revised periodically and revisited with the medical team.

Alternate Promotions

Mental health care providers also should consider involving other HCPs. Physical therapists and exercise physiologists are in a unique position to provide experiential exercise training. Some VA facilities include experiential exercise in their MOVE! program—veterans exercise together in the VA’s physical therapy gym while being monitored by a physical therapist.

Peer support specialists (PSPs) also are in a unique position to effectively provide experiential physical activity interventions at VA facilities. These PSPs are veterans who have physical or mental health problems but are far enough along in recovery to provide helpful services to other veterans with similar challenges.⁶⁶ Recent organizational efforts have increased the presence of PSPs in VA clinics. Peer support specialists use aspects of their recovery to help other veterans, provide supportive counseling, and facilitate activity groups, such as walking, hiking, golfing, and photography groups. Further, PSPs may not have to deal with MHCPs’ concerns regarding scope of practice and clinical boundaries vis-à-vis exercise interventions.

Other VA and community programs provide ways for veterans to engage in experiential physical activities. Some VA facilities have pools and gyms that provide open hours for veterans; some even offer free HCP guidance. Clinics also occasionally provide transportation to community gyms that offer veterans discounted memberships. Team Red, White, and Blue (https://www.teamrwb.org), Veterans Expeditions, (http://www.vetexpeditions.com) and other community organizations promote veterans’ physical activity by organizing events, such as endurance races, fly fishing, and mountaineering. By staying up-to-date on local community services, MHCPs can facilitate opportunities for experiential exercise alongside the psychotherapy services they provide.

Although valuable resources exist, veterans nevertheless encounter obstacles to exercise. For instance, many VA HCPs do not include physical therapy as a standard part of the MOVE! program. Others offer physical therapy not as an integrated service but as a separate, optional service, and attendance requires more initiative. Often, veterans are referred for physical therapy only if they have sustained an injury. Even when physical therapy or exercise physiology services are offered, many veterans have difficulty following through. Reasons include anxiety, time constraints, difficulty managing multiple appointments, and negative beliefs about exercise and physical therapy (eg, it will make me hurt, physical therapy is only for people recovering from an injury). Last, some veterans are reluctant to engage in peer-led or non-VA exercise programs.

Future Research

This article highlights the need for research in several areas. First, it would be helpful to know the extent to which VA MHCPs are already promoting physical activity for their patients and the ways in which they are using experiential exercise interventions. Research also will help determine the extent to which experiential exercise interventions can be effective in treating mental and physical health conditions not listed in Table 2 and any conditions for which exercise interventions may be contraindicated. The effectiveness of exercise therapy, as described by Sime, also warrants more investigation with randomized clinical trials.⁶² Further, it would be useful to know more about the extent and effectiveness of other experiential exercise available to veterans, whether through the MOVE! program or through other VA or community resources. This would help HCPs understand how to best promote physical activity in veterans with chronic physical and mental health needs.

Conclusion

Most people fall short of recommended levels of physical activity, and this is especially true of veterans, who also are at higher risk for chronic physical and mental health problems.^23,24 VA MHCPs are in a unique position to promote physical activity, and therapy programs that include experiential exercise may be particularly effective in helping veterans become and stay active. Other providers are well suited to provide experiential exercise opportunities, but MHCPs can simultaneously address the psychological factors that prevent veterans from engaging in exercise. Although VA MHCPs should continue to collaborate with other resources that can provide experiential exercise, they should also consider the potential benefit of experiential exercise within psychotherapy.

TORONTO—A mentally stimulating lifestyle may help to increase resilience to cognitive decline despite an unhealthy diet, according to research presented at the 2016 Alzheimer’s Association International Conference. “Our results show the role higher educational attainment, mentally stimulating work, and social engagement can play in protecting your brain from cognitive decline, counteracting some negative effects of an unhealthy diet,” said Matthew Parrott, PhD, of Baycrest Health Sciences in Toronto.

Previous studies have linked poor diet to cognitive decline. In addition, factors such as education and social engagement may be associated with cognitive reserve (ie, the ability of the brain to withstand damage and maintain function). To determine whether the relationship between diet quality and cognitive function depends on an individual’s level of cognitive reserve, Dr. Parrott and colleagues conducted a study in community-dwelling older adults.

Researchers analyzed data from a subset of 351 healthy older adults enrolled in the Quebec Longitudinal Study of Nutrition and Successful Aging (NuAge). Participants’ mean age was 74. Participants were free from cognitive impairment and had to be able to climb one flight of stairs or walk a city block unassisted and without stopping. They were followed for three years. Participants were classified as having a low or high level of cognitive reserve based on their years of formal education, the social and data complexity of the occupation at which they worked the longest, and current participation in social leisure activities.

At baseline, investigators assessed the diet of participants over the previous 12 months using a semi-quantitative food frequency questionnaire. Each person was then assigned a diet score based on adherence to a Western dietary pattern (eg, consumption of red and processed meats, potatoes, white bread, and prepackaged foods and sweets), which was defined as a poor diet.

Investigators quantified cognitive reserve as a binary composite score based on educational attainment, occupational complexity, and social engagement. Education was defined as self-reported formal education. Social engagement was measured by a social activities score from the Elderly Activities Inventory questionnaire. Occupational complexity was based on participants’ self-reported longest serving occupation. Cognitive function was measured using the Modified Mini-Mental State Examination.

Overall, poor diet was associated with more cognitive decline. Data suggested, however, that a mentally stimulating lifestyle, or high cognitive reserve, protected older adults with a poor diet against cognitive decline. The researchers concluded that older adults who had a mentally stimulating lifestyle and limited their consumption of unhealthy foods appeared to be at the least at risk of dementia, compared with other participants. Mental stimulation seemed to build cognitive reserve, which may potentially lower the risk of developing dementia despite a poor diet. Since the Western diet was associated with worse baseline cognitive function in those with high cognitive reserve, mental stimulation did not seem to provide complete protection from an unhealthy diet. After three years, however, people with low cognitive reserve and a poor diet performed the worst.

“I think the take-home message is that older adults with a low lifetime history of mental stimulation or cognitive reserve should be especially vigilant to limit consumption of foods associated with a typical Western diet because they appear most vulnerable to the adverse influence of a poor diet on cognitive function,” said Dr. Parrott. “Next steps include trying to understand whether these results are limited to specific cognitive domains (eg, memory and executive function) and to link this protective effect to biomarkers and indicators of neuropathology.”

—Erica Robinson

Suggested Reading

Jackson PA, Pialoux V, Corbett D, et al. Promoting brain health through exercise and diet in older adults: a physiological perspective. J Physiol. 2016;594(16):4485-4498.

TORONTO—A mentally stimulating lifestyle may help to increase resilience to cognitive decline despite an unhealthy diet, according to research presented at the 2016 Alzheimer’s Association International Conference. “Our results show the role higher educational attainment, mentally stimulating work, and social engagement can play in protecting your brain from cognitive decline, counteracting some negative effects of an unhealthy diet,” said Matthew Parrott, PhD, of Baycrest Health Sciences in Toronto.

Previous studies have linked poor diet to cognitive decline. In addition, factors such as education and social engagement may be associated with cognitive reserve (ie, the ability of the brain to withstand damage and maintain function). To determine whether the relationship between diet quality and cognitive function depends on an individual’s level of cognitive reserve, Dr. Parrott and colleagues conducted a study in community-dwelling older adults.

Researchers analyzed data from a subset of 351 healthy older adults enrolled in the Quebec Longitudinal Study of Nutrition and Successful Aging (NuAge). Participants’ mean age was 74. Participants were free from cognitive impairment and had to be able to climb one flight of stairs or walk a city block unassisted and without stopping. They were followed for three years. Participants were classified as having a low or high level of cognitive reserve based on their years of formal education, the social and data complexity of the occupation at which they worked the longest, and current participation in social leisure activities.

At baseline, investigators assessed the diet of participants over the previous 12 months using a semi-quantitative food frequency questionnaire. Each person was then assigned a diet score based on adherence to a Western dietary pattern (eg, consumption of red and processed meats, potatoes, white bread, and prepackaged foods and sweets), which was defined as a poor diet.

Investigators quantified cognitive reserve as a binary composite score based on educational attainment, occupational complexity, and social engagement. Education was defined as self-reported formal education. Social engagement was measured by a social activities score from the Elderly Activities Inventory questionnaire. Occupational complexity was based on participants’ self-reported longest serving occupation. Cognitive function was measured using the Modified Mini-Mental State Examination.

Overall, poor diet was associated with more cognitive decline. Data suggested, however, that a mentally stimulating lifestyle, or high cognitive reserve, protected older adults with a poor diet against cognitive decline. The researchers concluded that older adults who had a mentally stimulating lifestyle and limited their consumption of unhealthy foods appeared to be at the least at risk of dementia, compared with other participants. Mental stimulation seemed to build cognitive reserve, which may potentially lower the risk of developing dementia despite a poor diet. Since the Western diet was associated with worse baseline cognitive function in those with high cognitive reserve, mental stimulation did not seem to provide complete protection from an unhealthy diet. After three years, however, people with low cognitive reserve and a poor diet performed the worst.

“I think the take-home message is that older adults with a low lifetime history of mental stimulation or cognitive reserve should be especially vigilant to limit consumption of foods associated with a typical Western diet because they appear most vulnerable to the adverse influence of a poor diet on cognitive function,” said Dr. Parrott. “Next steps include trying to understand whether these results are limited to specific cognitive domains (eg, memory and executive function) and to link this protective effect to biomarkers and indicators of neuropathology.”

—Erica Robinson

Suggested Reading

Jackson PA, Pialoux V, Corbett D, et al. Promoting brain health through exercise and diet in older adults: a physiological perspective. J Physiol. 2016;594(16):4485-4498.

TORONTO—A mentally stimulating lifestyle may help to increase resilience to cognitive decline despite an unhealthy diet, according to research presented at the 2016 Alzheimer’s Association International Conference. “Our results show the role higher educational attainment, mentally stimulating work, and social engagement can play in protecting your brain from cognitive decline, counteracting some negative effects of an unhealthy diet,” said Matthew Parrott, PhD, of Baycrest Health Sciences in Toronto.

Previous studies have linked poor diet to cognitive decline. In addition, factors such as education and social engagement may be associated with cognitive reserve (ie, the ability of the brain to withstand damage and maintain function). To determine whether the relationship between diet quality and cognitive function depends on an individual’s level of cognitive reserve, Dr. Parrott and colleagues conducted a study in community-dwelling older adults.

Researchers analyzed data from a subset of 351 healthy older adults enrolled in the Quebec Longitudinal Study of Nutrition and Successful Aging (NuAge). Participants’ mean age was 74. Participants were free from cognitive impairment and had to be able to climb one flight of stairs or walk a city block unassisted and without stopping. They were followed for three years. Participants were classified as having a low or high level of cognitive reserve based on their years of formal education, the social and data complexity of the occupation at which they worked the longest, and current participation in social leisure activities.

At baseline, investigators assessed the diet of participants over the previous 12 months using a semi-quantitative food frequency questionnaire. Each person was then assigned a diet score based on adherence to a Western dietary pattern (eg, consumption of red and processed meats, potatoes, white bread, and prepackaged foods and sweets), which was defined as a poor diet.

Investigators quantified cognitive reserve as a binary composite score based on educational attainment, occupational complexity, and social engagement. Education was defined as self-reported formal education. Social engagement was measured by a social activities score from the Elderly Activities Inventory questionnaire. Occupational complexity was based on participants’ self-reported longest serving occupation. Cognitive function was measured using the Modified Mini-Mental State Examination.

Overall, poor diet was associated with more cognitive decline. Data suggested, however, that a mentally stimulating lifestyle, or high cognitive reserve, protected older adults with a poor diet against cognitive decline. The researchers concluded that older adults who had a mentally stimulating lifestyle and limited their consumption of unhealthy foods appeared to be at the least at risk of dementia, compared with other participants. Mental stimulation seemed to build cognitive reserve, which may potentially lower the risk of developing dementia despite a poor diet. Since the Western diet was associated with worse baseline cognitive function in those with high cognitive reserve, mental stimulation did not seem to provide complete protection from an unhealthy diet. After three years, however, people with low cognitive reserve and a poor diet performed the worst.

“I think the take-home message is that older adults with a low lifetime history of mental stimulation or cognitive reserve should be especially vigilant to limit consumption of foods associated with a typical Western diet because they appear most vulnerable to the adverse influence of a poor diet on cognitive function,” said Dr. Parrott. “Next steps include trying to understand whether these results are limited to specific cognitive domains (eg, memory and executive function) and to link this protective effect to biomarkers and indicators of neuropathology.”

—Erica Robinson

Suggested Reading

Jackson PA, Pialoux V, Corbett D, et al. Promoting brain health through exercise and diet in older adults: a physiological perspective. J Physiol. 2016;594(16):4485-4498.

LONDON—Evaluation of cortical lesions improves the specificity of the diagnostic criteria for multiple sclerosis (MS), according to research presented at the 32nd Congress of the European Committee for Treatment and Research in MS (ECTRIMS). Assessment of cortical lesions, in concert with current McDonald criteria, also preserved a high level of diagnostic sensitivity and accuracy in a multicentric cohort of patients with clinically isolated syndrome, reported Paolo Preziosa, MD, Neuroimaging Research Unit at the Institute of Experimental Neurology and Division of Neuroscience at San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy, and his research colleagues.

Since the publication of the 2010 revised McDonald criteria, new data regarding the application of MRI for the diagnosis of MS have become available. In a single-center study, adding the assessment of cortical lesions was shown to modify the diagnostic algorithm, resulting in higher specificity.

In the present study, Dr. Preziosa and colleagues sought to test the performance of different sets of imaging criteria, including the assessment of cortical lesions, for the development of MS in a multicentric cohort of patients with clinically isolated syndrome.

The researchers analyzed brain double inversion recovery and brain and cord T2-weighted and post-contrast T1-weighted sequences acquired from 72 patients with clinically isolated syndrome from five European centers (Barcelona, Belgrade, Mainz, Milan, and Verona) within three months and after 12 months from disease onset. Patients were followed clinically for 24 or more months or until the development of clinically defined MS. Median follow-up was 24.2 months. Sensitivity, specificity, and accuracy of the different dissemination in space MRI criteria for the development of MS were tested.

At follow-up, 65 patients (90%) had clinically and/or radiologically definite MS. The sensitivity of all criteria was high (McDonald 2005, 83%; McDonald 2010, 92%; Filippi 2010, 80%). Specificity of Filippi 2010 was higher (67%), compared with the others (50% for McDonald 2005 and 2010). The accuracy of all criteria was high (McDonald 2005, 81%; McDonald 2010, 89%; Filippi 2010, 79%).

“The detection of cortical lesions in vivo using MRI should be considered in future clinical trials,” Dr. Preziosa said.

—Glenn S. Williams

Suggested Reading

Filippi M, Rocca MA, Calabrese M, et al. Intracortical lesions: relevance for new MRI diagnostic criteria for multiple sclerosis. Neurology. 2010;75(22):1988-1994.

LONDON—Evaluation of cortical lesions improves the specificity of the diagnostic criteria for multiple sclerosis (MS), according to research presented at the 32nd Congress of the European Committee for Treatment and Research in MS (ECTRIMS). Assessment of cortical lesions, in concert with current McDonald criteria, also preserved a high level of diagnostic sensitivity and accuracy in a multicentric cohort of patients with clinically isolated syndrome, reported Paolo Preziosa, MD, Neuroimaging Research Unit at the Institute of Experimental Neurology and Division of Neuroscience at San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy, and his research colleagues.

Since the publication of the 2010 revised McDonald criteria, new data regarding the application of MRI for the diagnosis of MS have become available. In a single-center study, adding the assessment of cortical lesions was shown to modify the diagnostic algorithm, resulting in higher specificity.

In the present study, Dr. Preziosa and colleagues sought to test the performance of different sets of imaging criteria, including the assessment of cortical lesions, for the development of MS in a multicentric cohort of patients with clinically isolated syndrome.

The researchers analyzed brain double inversion recovery and brain and cord T2-weighted and post-contrast T1-weighted sequences acquired from 72 patients with clinically isolated syndrome from five European centers (Barcelona, Belgrade, Mainz, Milan, and Verona) within three months and after 12 months from disease onset. Patients were followed clinically for 24 or more months or until the development of clinically defined MS. Median follow-up was 24.2 months. Sensitivity, specificity, and accuracy of the different dissemination in space MRI criteria for the development of MS were tested.

At follow-up, 65 patients (90%) had clinically and/or radiologically definite MS. The sensitivity of all criteria was high (McDonald 2005, 83%; McDonald 2010, 92%; Filippi 2010, 80%). Specificity of Filippi 2010 was higher (67%), compared with the others (50% for McDonald 2005 and 2010). The accuracy of all criteria was high (McDonald 2005, 81%; McDonald 2010, 89%; Filippi 2010, 79%).

“The detection of cortical lesions in vivo using MRI should be considered in future clinical trials,” Dr. Preziosa said.

—Glenn S. Williams

Suggested Reading

Filippi M, Rocca MA, Calabrese M, et al. Intracortical lesions: relevance for new MRI diagnostic criteria for multiple sclerosis. Neurology. 2010;75(22):1988-1994.

LONDON—Evaluation of cortical lesions improves the specificity of the diagnostic criteria for multiple sclerosis (MS), according to research presented at the 32nd Congress of the European Committee for Treatment and Research in MS (ECTRIMS). Assessment of cortical lesions, in concert with current McDonald criteria, also preserved a high level of diagnostic sensitivity and accuracy in a multicentric cohort of patients with clinically isolated syndrome, reported Paolo Preziosa, MD, Neuroimaging Research Unit at the Institute of Experimental Neurology and Division of Neuroscience at San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy, and his research colleagues.

Since the publication of the 2010 revised McDonald criteria, new data regarding the application of MRI for the diagnosis of MS have become available. In a single-center study, adding the assessment of cortical lesions was shown to modify the diagnostic algorithm, resulting in higher specificity.

In the present study, Dr. Preziosa and colleagues sought to test the performance of different sets of imaging criteria, including the assessment of cortical lesions, for the development of MS in a multicentric cohort of patients with clinically isolated syndrome.

The researchers analyzed brain double inversion recovery and brain and cord T2-weighted and post-contrast T1-weighted sequences acquired from 72 patients with clinically isolated syndrome from five European centers (Barcelona, Belgrade, Mainz, Milan, and Verona) within three months and after 12 months from disease onset. Patients were followed clinically for 24 or more months or until the development of clinically defined MS. Median follow-up was 24.2 months. Sensitivity, specificity, and accuracy of the different dissemination in space MRI criteria for the development of MS were tested.

At follow-up, 65 patients (90%) had clinically and/or radiologically definite MS. The sensitivity of all criteria was high (McDonald 2005, 83%; McDonald 2010, 92%; Filippi 2010, 80%). Specificity of Filippi 2010 was higher (67%), compared with the others (50% for McDonald 2005 and 2010). The accuracy of all criteria was high (McDonald 2005, 81%; McDonald 2010, 89%; Filippi 2010, 79%).

“The detection of cortical lesions in vivo using MRI should be considered in future clinical trials,” Dr. Preziosa said.

—Glenn S. Williams

Suggested Reading

Filippi M, Rocca MA, Calabrese M, et al. Intracortical lesions: relevance for new MRI diagnostic criteria for multiple sclerosis. Neurology. 2010;75(22):1988-1994.

LONDON – Severe vitamin D deficiency and current smoking predicted accumulated disability in patients with clinically isolated syndrome, which can be a precursor to the development of multiple sclerosis.

Prospectively collected data from the ongoing Barcelona clinically isolated syndrome (CIS) cohort, which includes more than 1,000 patients with CIS, showed that patients with a serum vitamin D below 8.0 ng/mL (9% of 503 patient samples) had more than double the risk for accumulated disability when compared with those who had higher vitamin D levels. The hazard ratio for disability with severely low vitamin D levels was 2.3 (P = .049) in an analysis adjusted for the potential confounding factors of patients’ sex and age, the number of baseline T2 lesions, receipt of disease-modifying treatment, CIS topography, and oligoclonal bands. Disability accumulation was defined as an Expanded Disability Status Scale score of 3.0 or more.

LONDON – Severe vitamin D deficiency and current smoking predicted accumulated disability in patients with clinically isolated syndrome, which can be a precursor to the development of multiple sclerosis.

Prospectively collected data from the ongoing Barcelona clinically isolated syndrome (CIS) cohort, which includes more than 1,000 patients with CIS, showed that patients with a serum vitamin D below 8.0 ng/mL (9% of 503 patient samples) had more than double the risk for accumulated disability when compared with those who had higher vitamin D levels. The hazard ratio for disability with severely low vitamin D levels was 2.3 (P = .049) in an analysis adjusted for the potential confounding factors of patients’ sex and age, the number of baseline T2 lesions, receipt of disease-modifying treatment, CIS topography, and oligoclonal bands. Disability accumulation was defined as an Expanded Disability Status Scale score of 3.0 or more.

LONDON – Severe vitamin D deficiency and current smoking predicted accumulated disability in patients with clinically isolated syndrome, which can be a precursor to the development of multiple sclerosis.

Prospectively collected data from the ongoing Barcelona clinically isolated syndrome (CIS) cohort, which includes more than 1,000 patients with CIS, showed that patients with a serum vitamin D below 8.0 ng/mL (9% of 503 patient samples) had more than double the risk for accumulated disability when compared with those who had higher vitamin D levels. The hazard ratio for disability with severely low vitamin D levels was 2.3 (P = .049) in an analysis adjusted for the potential confounding factors of patients’ sex and age, the number of baseline T2 lesions, receipt of disease-modifying treatment, CIS topography, and oligoclonal bands. Disability accumulation was defined as an Expanded Disability Status Scale score of 3.0 or more.

PORTLAND, OR—In patients with idiopathic REM sleep behavior disorder, microglial activation is increased in the substantia nigra, compared with controls, and microglial activation correlates with putamenal dopaminergic dysfunction, according to research presented at the Fourth World Parkinson Congress. These findings suggest that “anti-inflammatory agents could possibly delay progression to a manifest synucleinopathy in subjects with idiopathic REM sleep behavior disorder,” researchers said.

Longitudinal studies have found that patients with idiopathic REM sleep behavior disorder have an increased risk of Parkinson’s disease and related Lewy body disorders. “This implies that, in idiopathic REM sleep behavior disorder, the underlying pathology of developing neurodegenerative disorders can be investigated years prior to the development of manifest symptoms,” said Morten Gersel Stokholm, MD, a researcher in the Department of Clinical Medicine at Aarhus University and the Department of Nuclear Medicine & PET-Centre at Aarhus University Hospital, Denmark, and his research colleagues.

To investigate the in vivo occurrence of neuroinflammation in the brains of patients with idiopathic REM sleep behavior disorder and neuroinflammation’s temporal relationship with striatal dopamine dysfunction, Dr. Stokholm and colleagues conducted a multitracer PET study of patients with idiopathic REM sleep behavior disorder.

The investigators enrolled 15 patients with polysomnography-confirmed idiopathic REM sleep behavior disorder at Aarhus University Hospital and Hospital Clínic de Barcelona. They also enrolled 19 matched controls. Participants underwent two PET scans with 18F-DOPA and 11C-PK11195 and a structural T1 MRI scan. Parametric images of specific tracer uptake (ie, F-dopa Ki-values and PK11195 binding potential) were constructed at voxel level using Patlak graphical analysis and a supervised cluster-analysis with compartmental modeling, respectively. A region of interest analysis was performed on a priori defined regions.

Compared with controls, patients with idiopathic REM sleep behavior disorder showed significantly reduced 18F-DOPA tracer uptake in the substantia nigra. Patients with higher substantia nigra11C-PK11195 binding also had increased binding in the ipsilateral putamen. Patients with more severe reductions in putamenal 18F-DOPA uptake had significantly higher 11C-PK11195 binding in the putamen and substantia nigra.

—Jake Remaly

PORTLAND, OR—In patients with idiopathic REM sleep behavior disorder, microglial activation is increased in the substantia nigra, compared with controls, and microglial activation correlates with putamenal dopaminergic dysfunction, according to research presented at the Fourth World Parkinson Congress. These findings suggest that “anti-inflammatory agents could possibly delay progression to a manifest synucleinopathy in subjects with idiopathic REM sleep behavior disorder,” researchers said.

Longitudinal studies have found that patients with idiopathic REM sleep behavior disorder have an increased risk of Parkinson’s disease and related Lewy body disorders. “This implies that, in idiopathic REM sleep behavior disorder, the underlying pathology of developing neurodegenerative disorders can be investigated years prior to the development of manifest symptoms,” said Morten Gersel Stokholm, MD, a researcher in the Department of Clinical Medicine at Aarhus University and the Department of Nuclear Medicine & PET-Centre at Aarhus University Hospital, Denmark, and his research colleagues.

To investigate the in vivo occurrence of neuroinflammation in the brains of patients with idiopathic REM sleep behavior disorder and neuroinflammation’s temporal relationship with striatal dopamine dysfunction, Dr. Stokholm and colleagues conducted a multitracer PET study of patients with idiopathic REM sleep behavior disorder.

The investigators enrolled 15 patients with polysomnography-confirmed idiopathic REM sleep behavior disorder at Aarhus University Hospital and Hospital Clínic de Barcelona. They also enrolled 19 matched controls. Participants underwent two PET scans with 18F-DOPA and 11C-PK11195 and a structural T1 MRI scan. Parametric images of specific tracer uptake (ie, F-dopa Ki-values and PK11195 binding potential) were constructed at voxel level using Patlak graphical analysis and a supervised cluster-analysis with compartmental modeling, respectively. A region of interest analysis was performed on a priori defined regions.

Compared with controls, patients with idiopathic REM sleep behavior disorder showed significantly reduced 18F-DOPA tracer uptake in the substantia nigra. Patients with higher substantia nigra11C-PK11195 binding also had increased binding in the ipsilateral putamen. Patients with more severe reductions in putamenal 18F-DOPA uptake had significantly higher 11C-PK11195 binding in the putamen and substantia nigra.

—Jake Remaly

PORTLAND, OR—In patients with idiopathic REM sleep behavior disorder, microglial activation is increased in the substantia nigra, compared with controls, and microglial activation correlates with putamenal dopaminergic dysfunction, according to research presented at the Fourth World Parkinson Congress. These findings suggest that “anti-inflammatory agents could possibly delay progression to a manifest synucleinopathy in subjects with idiopathic REM sleep behavior disorder,” researchers said.

Longitudinal studies have found that patients with idiopathic REM sleep behavior disorder have an increased risk of Parkinson’s disease and related Lewy body disorders. “This implies that, in idiopathic REM sleep behavior disorder, the underlying pathology of developing neurodegenerative disorders can be investigated years prior to the development of manifest symptoms,” said Morten Gersel Stokholm, MD, a researcher in the Department of Clinical Medicine at Aarhus University and the Department of Nuclear Medicine & PET-Centre at Aarhus University Hospital, Denmark, and his research colleagues.

To investigate the in vivo occurrence of neuroinflammation in the brains of patients with idiopathic REM sleep behavior disorder and neuroinflammation’s temporal relationship with striatal dopamine dysfunction, Dr. Stokholm and colleagues conducted a multitracer PET study of patients with idiopathic REM sleep behavior disorder.

The investigators enrolled 15 patients with polysomnography-confirmed idiopathic REM sleep behavior disorder at Aarhus University Hospital and Hospital Clínic de Barcelona. They also enrolled 19 matched controls. Participants underwent two PET scans with 18F-DOPA and 11C-PK11195 and a structural T1 MRI scan. Parametric images of specific tracer uptake (ie, F-dopa Ki-values and PK11195 binding potential) were constructed at voxel level using Patlak graphical analysis and a supervised cluster-analysis with compartmental modeling, respectively. A region of interest analysis was performed on a priori defined regions.

Compared with controls, patients with idiopathic REM sleep behavior disorder showed significantly reduced 18F-DOPA tracer uptake in the substantia nigra. Patients with higher substantia nigra11C-PK11195 binding also had increased binding in the ipsilateral putamen. Patients with more severe reductions in putamenal 18F-DOPA uptake had significantly higher 11C-PK11195 binding in the putamen and substantia nigra.

—Jake Remaly

PORTLAND, OR—Among patients with Parkinson’s disease, eating foods common in a Mediterranean diet and exercising regularly are associated with reduced rates of Parkinson’s disease progression, according to the results of a natural history study described at the Fourth World Parkinson Congress.

To evaluate whether diet, exercise, and supplements are associated with rate of Parkinson’s disease progression, Laurie Mischley, ND, PhD, MPH, Assistant Research Scientist at Bastyr University Research Institute in Kenmore, Washington, and Richard Lau, MPH, a PhD student in the College of Public Health and Human Sciences at Oregon State University in Corvalis conducted an Internet-based natural history study. A total of 1,024 patients participated in the study. Participants had a mean age of 60.7 and had been diagnosed with Parkinson’s disease for an average of 6.7 years.

The researchers used the Patient-Reported Outcomes in Parkinson’s Disease (PRO-PD) scale to assess Parkinson’s disease severity. Disease progression was defined as PRO-PD score adjusted for age and years since diagnosis. They used baseline food frequency questionnaires to quantify dietary intake in the cross-sectional analysis.

Fresh fruit, fresh vegetables, nuts and seeds, olive oil, fish (non-fried), wine, eggs, and fresh herbs were associated with a statistically significant improvement in PRO-PD score, the researchers said. Fried foods, beef, diet soda, canned fruits, and canned vegetables were associated with more severe disease. Dairy consumption was not associated with disease severity.

Of the supplements and pharmaceuticals studied, oral glutathione, rasagiline, and coenzyme Q10 were associated with improved PRO-PD scores, whereas iron was associated with more severe disease. The effect of melatonin was not significant, however, when the researchers considered poor sleep. The researchers observed a dose-response curve with exercise. Exercising at least 30 minutes daily was associated with the greatest reduction in disease severity.

“Whether iron, fried foods, diet soda, or canned goods provide environmental insults that accelerate disease progression warrants immediate attention,” the researchers concluded. “This pragmatic natural history study offers the first evidence base for prescribing lifestyle modification (beyond exercise) to patients with Parkinson’s disease. Patients should ... know that they can make choices that affect outcomes.”

—Jake Remaly

PORTLAND, OR—Among patients with Parkinson’s disease, eating foods common in a Mediterranean diet and exercising regularly are associated with reduced rates of Parkinson’s disease progression, according to the results of a natural history study described at the Fourth World Parkinson Congress.

To evaluate whether diet, exercise, and supplements are associated with rate of Parkinson’s disease progression, Laurie Mischley, ND, PhD, MPH, Assistant Research Scientist at Bastyr University Research Institute in Kenmore, Washington, and Richard Lau, MPH, a PhD student in the College of Public Health and Human Sciences at Oregon State University in Corvalis conducted an Internet-based natural history study. A total of 1,024 patients participated in the study. Participants had a mean age of 60.7 and had been diagnosed with Parkinson’s disease for an average of 6.7 years.

The researchers used the Patient-Reported Outcomes in Parkinson’s Disease (PRO-PD) scale to assess Parkinson’s disease severity. Disease progression was defined as PRO-PD score adjusted for age and years since diagnosis. They used baseline food frequency questionnaires to quantify dietary intake in the cross-sectional analysis.

Fresh fruit, fresh vegetables, nuts and seeds, olive oil, fish (non-fried), wine, eggs, and fresh herbs were associated with a statistically significant improvement in PRO-PD score, the researchers said. Fried foods, beef, diet soda, canned fruits, and canned vegetables were associated with more severe disease. Dairy consumption was not associated with disease severity.

Of the supplements and pharmaceuticals studied, oral glutathione, rasagiline, and coenzyme Q10 were associated with improved PRO-PD scores, whereas iron was associated with more severe disease. The effect of melatonin was not significant, however, when the researchers considered poor sleep. The researchers observed a dose-response curve with exercise. Exercising at least 30 minutes daily was associated with the greatest reduction in disease severity.

“Whether iron, fried foods, diet soda, or canned goods provide environmental insults that accelerate disease progression warrants immediate attention,” the researchers concluded. “This pragmatic natural history study offers the first evidence base for prescribing lifestyle modification (beyond exercise) to patients with Parkinson’s disease. Patients should ... know that they can make choices that affect outcomes.”

—Jake Remaly

PORTLAND, OR—Among patients with Parkinson’s disease, eating foods common in a Mediterranean diet and exercising regularly are associated with reduced rates of Parkinson’s disease progression, according to the results of a natural history study described at the Fourth World Parkinson Congress.

To evaluate whether diet, exercise, and supplements are associated with rate of Parkinson’s disease progression, Laurie Mischley, ND, PhD, MPH, Assistant Research Scientist at Bastyr University Research Institute in Kenmore, Washington, and Richard Lau, MPH, a PhD student in the College of Public Health and Human Sciences at Oregon State University in Corvalis conducted an Internet-based natural history study. A total of 1,024 patients participated in the study. Participants had a mean age of 60.7 and had been diagnosed with Parkinson’s disease for an average of 6.7 years.

The researchers used the Patient-Reported Outcomes in Parkinson’s Disease (PRO-PD) scale to assess Parkinson’s disease severity. Disease progression was defined as PRO-PD score adjusted for age and years since diagnosis. They used baseline food frequency questionnaires to quantify dietary intake in the cross-sectional analysis.

Fresh fruit, fresh vegetables, nuts and seeds, olive oil, fish (non-fried), wine, eggs, and fresh herbs were associated with a statistically significant improvement in PRO-PD score, the researchers said. Fried foods, beef, diet soda, canned fruits, and canned vegetables were associated with more severe disease. Dairy consumption was not associated with disease severity.

Of the supplements and pharmaceuticals studied, oral glutathione, rasagiline, and coenzyme Q10 were associated with improved PRO-PD scores, whereas iron was associated with more severe disease. The effect of melatonin was not significant, however, when the researchers considered poor sleep. The researchers observed a dose-response curve with exercise. Exercising at least 30 minutes daily was associated with the greatest reduction in disease severity.

“Whether iron, fried foods, diet soda, or canned goods provide environmental insults that accelerate disease progression warrants immediate attention,” the researchers concluded. “This pragmatic natural history study offers the first evidence base for prescribing lifestyle modification (beyond exercise) to patients with Parkinson’s disease. Patients should ... know that they can make choices that affect outcomes.”

—Jake Remaly

Total hip arthroplasty (THA) has revolutionized the practice of orthopedic surgery. The number of primary THAs performed in the United States alone is predicted to rise to 572,000 per year by 2030.¹ Increasing demand requires a tighter focus on cost-effectiveness, particularly with regard to expensive postoperative complications. Trunnionosis and taper corrosion have recently emerged as problems in THA.^2-7 No longer restricted to metal-on-metal bearings, these phenomena now affect an increasing number of metal-on-polyethylene THAs and are exacerbated by modularity.⁸ The emergence of these complications adds complexity to the diagnostic algorithm in patients who present with painful THAs. Furthermore, the diagnosis of either trunnionosis or taper corrosion calls for revision surgery. In response to the increase in these complications, a group of orthopedic professional societies developed an algorithm for managing suspected metal toxicity issues.⁹ However, increases in toxicity and patient morbidity, and the added costs of toxicity surveillance and revision surgery, will place a substantial economic burden on many health systems at a time when policy makers are implementing substantial changes to health delivery in an effort to contain costs while improving patient outcomes.

Although they are more expensive than cobalt-chrome heads, ceramic femoral heads make metal toxicity a nonissue and eliminate the need for toxicity surveillance protocols. Furthermore, ceramic femoral heads are thought to have longevity advantages (this relationship needs to be confirmed in long-term studies).

In this article, we provide a theoretical framework for debating whether use of ceramic femoral heads in all THA patients could represent a more cost-effective option over the long term.

Materials and Methods

Guidelines for the diagnostic algorithm for painful THA with suspected metal toxicity were obtained from a recent orthopedic professional society consensus statement.⁹ The cost of this work-up was obtained from the finance department at our institution (Table 1).

We created 2 metrics to analyze the cost difference between ceramic and cobalt-chrome femoral heads. The first metric was “ceramic surplus,” the extra cost of a ceramic femoral head above that of a cobalt-chrome femoral head, and the second was “maximum ceramic surplus,” the ceramic surplus cutoff value for which using ceramic femoral heads in all patients becomes more cost-effective than using cobalt-chrome heads.

Results

A single metal toxicity work-up cost $5085 with MARS-MRI and $2402 with US (Table 1). Revision THA with a 3-day inpatient stay cost $53,320, and that figure does not include the cost of surgical implants or perioperative medications and devices, all of which have highly variable cost structures (Table 1). Ceramic surplus was as low as $500 in a high-volume academic practice and as high as $1500 in a low-volume private practice (Table 2). Maximum ceramic surplus ranged from $511 to $2044 in the models integrating MARS-MRI and from $488 to $1950 in the models integrating US (Table 3).

Discussion

Trunnionosis, corrosion, and metal toxicity are of increasing concern in hip implants that incorporate a cobalt-chrome femoral head, regardless of the counterpart articulation surface (metal, ceramic, polyethylene).^2-8 In response to the added diagnostic challenge raised by these phenomena, a group of orthopedic professional societies developed an algorithm that can guide surgeons in the management of suspected corrosion or metal toxicity.⁹ In this protocol, toxicity surveillance in conjunction with potential revision surgery for metal-associated complications has the potential to increase patient morbidity and place a significant economic burden on many health systems. Given the recent emergence of trunnionosis, epidemiologic data on this complication are lacking.¹⁰ However, there is a substantial body of evidence showing devastating complications associated with adverse reactions to metal debris.^11-17

Given the potential complications specific to cobalt-chrome femoral heads, we wanted to provide a theoretical framework for debating whether use of ceramic heads in all patients has the potential to be a more cost-effective option over the long term. Ceramic femoral heads are premium implants, certainly more expensive at initial point of care. One study based on a large community registry showed premium implants (eg, ceramic femoral heads) add a surplus averaging $1000.¹⁸ In our investigation, ceramic surplus varied with practice setting, from $500 to $1500. Lower costs were discovered in high-volume practice settings, indicating that a shift to increased use of ceramic femoral heads would likely decrease ceramic surplus for most institutions.

We used a series of simulations to predict maximum ceramic surplus after manipulation of theoretical incidence ratios. The main limitation of this study was our use of 7% as the incidence of painful THA within 1- to 2-year follow-up. This point estimate was derived from a manuscript that to our knowledge provides the most realistic estimate of this complication¹⁰; with use of more complete data in upcoming studies, however, the 7% figure could certainly change. As data are also lacking on the proportion of painful THAs that receive a metal work-up and on the proportion of metal work-ups that indicate revision surgery, we modeled values of 12.5%, 25%, and 50% for each of these metrics to cover a wide range of possibilities.

It is also true the model did not incorporate scenarios to account for the law of unintended consequences, which would caution that using ceramics for all patients may bring a new set of complications. Zirconia ceramic bearings have tended to fracture, with the vast majority of fractures occurring in the liner of ceramic-on-ceramic articulations. Midterm reports and laboratory data suggest this issue has largely been solved with the advent of delta ceramics, a composite containing only a small fraction of zirconia.^19,20 Nevertheless, longer term in vivo data are needed to confirm the stability, longevity, and complication profile of these materials.

A final limitation of the present study is that the cost of a single metal toxicity work-up was based on just one institution. Grossly differing cost structures in other markets could alter the economic risk–benefit analysis we have described. However, we should note that the costs of tests, procedures, and appointments at our institution were uniform across a wide variety of practice settings in multiple regions of the United States, and thus are likely similar to the costs at a majority of practices.

Although our model took some liberties by necessity, it was also quite conservative in many respects. Many patients who undergo surveillance for metal toxicity undergo serial follow-ups; for this analysis, however, we considered the cost of only a single work-up. In addition, our proposed cost of revision surgery accounts only for facility and personnel costs during a 3-day inpatient stay and does not include the costs of implants, perioperative medications and devices, follow-up care, and potentially longer hospital stays or subsequent procedures, all of which can be highly variable and add considerable cost. Had any or all of these factors been incorporated into more complex modeling, the potential economic benefits of ceramic femoral heads would have been significantly greater.

After taking all these factors into account, our model found that maximum ceramic surplus ranged from $488 to $2044, depending on theoretical incidence ratio and imaging modality (Table 3). The lowest maximum ceramic surplus values ($511 for MARS-MRI protocol, $488 for US protocol) were based on the assumption that only 12.5% of patients who present with a painful THA receive a single metal work-up (0.875% of all THAs) and that only 12.5% of those patients are eventually revised (0.11% of all THAs). This outcome suggests ceramic femoral heads could be more cost-effective than cobalt-chrome femoral heads under these conservative projections when considering ceramic surplus is already as low as $500 at some high-volume centers. This figure would likely decline further in parallel with widespread growth in demand. Further study on the epidemiology of trunnionosis, corrosion, and metal toxicity in metal-on-polyethylene THA is needed to evaluate the economic validity of this proposal. Nevertheless, the superior safety profile of ceramic femoral heads with regard to metal toxicity indicates that wholesale use in THAs may in fact provide the most economical option on a societal scale.

Am J Orthop. 2016;45(6):E362-E366. Copyright Frontline Medical Communications Inc. 2016. All rights reserved.

Total hip arthroplasty (THA) has revolutionized the practice of orthopedic surgery. The number of primary THAs performed in the United States alone is predicted to rise to 572,000 per year by 2030.¹ Increasing demand requires a tighter focus on cost-effectiveness, particularly with regard to expensive postoperative complications. Trunnionosis and taper corrosion have recently emerged as problems in THA.^2-7 No longer restricted to metal-on-metal bearings, these phenomena now affect an increasing number of metal-on-polyethylene THAs and are exacerbated by modularity.⁸ The emergence of these complications adds complexity to the diagnostic algorithm in patients who present with painful THAs. Furthermore, the diagnosis of either trunnionosis or taper corrosion calls for revision surgery. In response to the increase in these complications, a group of orthopedic professional societies developed an algorithm for managing suspected metal toxicity issues.⁹ However, increases in toxicity and patient morbidity, and the added costs of toxicity surveillance and revision surgery, will place a substantial economic burden on many health systems at a time when policy makers are implementing substantial changes to health delivery in an effort to contain costs while improving patient outcomes.

Although they are more expensive than cobalt-chrome heads, ceramic femoral heads make metal toxicity a nonissue and eliminate the need for toxicity surveillance protocols. Furthermore, ceramic femoral heads are thought to have longevity advantages (this relationship needs to be confirmed in long-term studies).

In this article, we provide a theoretical framework for debating whether use of ceramic femoral heads in all THA patients could represent a more cost-effective option over the long term.

Materials and Methods

Guidelines for the diagnostic algorithm for painful THA with suspected metal toxicity were obtained from a recent orthopedic professional society consensus statement.⁹ The cost of this work-up was obtained from the finance department at our institution (Table 1).

We created 2 metrics to analyze the cost difference between ceramic and cobalt-chrome femoral heads. The first metric was “ceramic surplus,” the extra cost of a ceramic femoral head above that of a cobalt-chrome femoral head, and the second was “maximum ceramic surplus,” the ceramic surplus cutoff value for which using ceramic femoral heads in all patients becomes more cost-effective than using cobalt-chrome heads.

Results

A single metal toxicity work-up cost $5085 with MARS-MRI and $2402 with US (Table 1). Revision THA with a 3-day inpatient stay cost $53,320, and that figure does not include the cost of surgical implants or perioperative medications and devices, all of which have highly variable cost structures (Table 1). Ceramic surplus was as low as $500 in a high-volume academic practice and as high as $1500 in a low-volume private practice (Table 2). Maximum ceramic surplus ranged from $511 to $2044 in the models integrating MARS-MRI and from $488 to $1950 in the models integrating US (Table 3).

Discussion

Trunnionosis, corrosion, and metal toxicity are of increasing concern in hip implants that incorporate a cobalt-chrome femoral head, regardless of the counterpart articulation surface (metal, ceramic, polyethylene).^2-8 In response to the added diagnostic challenge raised by these phenomena, a group of orthopedic professional societies developed an algorithm that can guide surgeons in the management of suspected corrosion or metal toxicity.⁹ In this protocol, toxicity surveillance in conjunction with potential revision surgery for metal-associated complications has the potential to increase patient morbidity and place a significant economic burden on many health systems. Given the recent emergence of trunnionosis, epidemiologic data on this complication are lacking.¹⁰ However, there is a substantial body of evidence showing devastating complications associated with adverse reactions to metal debris.^11-17

Given the potential complications specific to cobalt-chrome femoral heads, we wanted to provide a theoretical framework for debating whether use of ceramic heads in all patients has the potential to be a more cost-effective option over the long term. Ceramic femoral heads are premium implants, certainly more expensive at initial point of care. One study based on a large community registry showed premium implants (eg, ceramic femoral heads) add a surplus averaging $1000.¹⁸ In our investigation, ceramic surplus varied with practice setting, from $500 to $1500. Lower costs were discovered in high-volume practice settings, indicating that a shift to increased use of ceramic femoral heads would likely decrease ceramic surplus for most institutions.

We used a series of simulations to predict maximum ceramic surplus after manipulation of theoretical incidence ratios. The main limitation of this study was our use of 7% as the incidence of painful THA within 1- to 2-year follow-up. This point estimate was derived from a manuscript that to our knowledge provides the most realistic estimate of this complication¹⁰; with use of more complete data in upcoming studies, however, the 7% figure could certainly change. As data are also lacking on the proportion of painful THAs that receive a metal work-up and on the proportion of metal work-ups that indicate revision surgery, we modeled values of 12.5%, 25%, and 50% for each of these metrics to cover a wide range of possibilities.

It is also true the model did not incorporate scenarios to account for the law of unintended consequences, which would caution that using ceramics for all patients may bring a new set of complications. Zirconia ceramic bearings have tended to fracture, with the vast majority of fractures occurring in the liner of ceramic-on-ceramic articulations. Midterm reports and laboratory data suggest this issue has largely been solved with the advent of delta ceramics, a composite containing only a small fraction of zirconia.^19,20 Nevertheless, longer term in vivo data are needed to confirm the stability, longevity, and complication profile of these materials.

A final limitation of the present study is that the cost of a single metal toxicity work-up was based on just one institution. Grossly differing cost structures in other markets could alter the economic risk–benefit analysis we have described. However, we should note that the costs of tests, procedures, and appointments at our institution were uniform across a wide variety of practice settings in multiple regions of the United States, and thus are likely similar to the costs at a majority of practices.

Although our model took some liberties by necessity, it was also quite conservative in many respects. Many patients who undergo surveillance for metal toxicity undergo serial follow-ups; for this analysis, however, we considered the cost of only a single work-up. In addition, our proposed cost of revision surgery accounts only for facility and personnel costs during a 3-day inpatient stay and does not include the costs of implants, perioperative medications and devices, follow-up care, and potentially longer hospital stays or subsequent procedures, all of which can be highly variable and add considerable cost. Had any or all of these factors been incorporated into more complex modeling, the potential economic benefits of ceramic femoral heads would have been significantly greater.

After taking all these factors into account, our model found that maximum ceramic surplus ranged from $488 to $2044, depending on theoretical incidence ratio and imaging modality (Table 3). The lowest maximum ceramic surplus values ($511 for MARS-MRI protocol, $488 for US protocol) were based on the assumption that only 12.5% of patients who present with a painful THA receive a single metal work-up (0.875% of all THAs) and that only 12.5% of those patients are eventually revised (0.11% of all THAs). This outcome suggests ceramic femoral heads could be more cost-effective than cobalt-chrome femoral heads under these conservative projections when considering ceramic surplus is already as low as $500 at some high-volume centers. This figure would likely decline further in parallel with widespread growth in demand. Further study on the epidemiology of trunnionosis, corrosion, and metal toxicity in metal-on-polyethylene THA is needed to evaluate the economic validity of this proposal. Nevertheless, the superior safety profile of ceramic femoral heads with regard to metal toxicity indicates that wholesale use in THAs may in fact provide the most economical option on a societal scale.

Am J Orthop. 2016;45(6):E362-E366. Copyright Frontline Medical Communications Inc. 2016. All rights reserved.

Total hip arthroplasty (THA) has revolutionized the practice of orthopedic surgery. The number of primary THAs performed in the United States alone is predicted to rise to 572,000 per year by 2030.¹ Increasing demand requires a tighter focus on cost-effectiveness, particularly with regard to expensive postoperative complications. Trunnionosis and taper corrosion have recently emerged as problems in THA.^2-7 No longer restricted to metal-on-metal bearings, these phenomena now affect an increasing number of metal-on-polyethylene THAs and are exacerbated by modularity.⁸ The emergence of these complications adds complexity to the diagnostic algorithm in patients who present with painful THAs. Furthermore, the diagnosis of either trunnionosis or taper corrosion calls for revision surgery. In response to the increase in these complications, a group of orthopedic professional societies developed an algorithm for managing suspected metal toxicity issues.⁹ However, increases in toxicity and patient morbidity, and the added costs of toxicity surveillance and revision surgery, will place a substantial economic burden on many health systems at a time when policy makers are implementing substantial changes to health delivery in an effort to contain costs while improving patient outcomes.

Although they are more expensive than cobalt-chrome heads, ceramic femoral heads make metal toxicity a nonissue and eliminate the need for toxicity surveillance protocols. Furthermore, ceramic femoral heads are thought to have longevity advantages (this relationship needs to be confirmed in long-term studies).

In this article, we provide a theoretical framework for debating whether use of ceramic femoral heads in all THA patients could represent a more cost-effective option over the long term.

Materials and Methods

Guidelines for the diagnostic algorithm for painful THA with suspected metal toxicity were obtained from a recent orthopedic professional society consensus statement.⁹ The cost of this work-up was obtained from the finance department at our institution (Table 1).

We created 2 metrics to analyze the cost difference between ceramic and cobalt-chrome femoral heads. The first metric was “ceramic surplus,” the extra cost of a ceramic femoral head above that of a cobalt-chrome femoral head, and the second was “maximum ceramic surplus,” the ceramic surplus cutoff value for which using ceramic femoral heads in all patients becomes more cost-effective than using cobalt-chrome heads.

Results

A single metal toxicity work-up cost $5085 with MARS-MRI and $2402 with US (Table 1). Revision THA with a 3-day inpatient stay cost $53,320, and that figure does not include the cost of surgical implants or perioperative medications and devices, all of which have highly variable cost structures (Table 1). Ceramic surplus was as low as $500 in a high-volume academic practice and as high as $1500 in a low-volume private practice (Table 2). Maximum ceramic surplus ranged from $511 to $2044 in the models integrating MARS-MRI and from $488 to $1950 in the models integrating US (Table 3).

Discussion

Trunnionosis, corrosion, and metal toxicity are of increasing concern in hip implants that incorporate a cobalt-chrome femoral head, regardless of the counterpart articulation surface (metal, ceramic, polyethylene).^2-8 In response to the added diagnostic challenge raised by these phenomena, a group of orthopedic professional societies developed an algorithm that can guide surgeons in the management of suspected corrosion or metal toxicity.⁹ In this protocol, toxicity surveillance in conjunction with potential revision surgery for metal-associated complications has the potential to increase patient morbidity and place a significant economic burden on many health systems. Given the recent emergence of trunnionosis, epidemiologic data on this complication are lacking.¹⁰ However, there is a substantial body of evidence showing devastating complications associated with adverse reactions to metal debris.^11-17

Given the potential complications specific to cobalt-chrome femoral heads, we wanted to provide a theoretical framework for debating whether use of ceramic heads in all patients has the potential to be a more cost-effective option over the long term. Ceramic femoral heads are premium implants, certainly more expensive at initial point of care. One study based on a large community registry showed premium implants (eg, ceramic femoral heads) add a surplus averaging $1000.¹⁸ In our investigation, ceramic surplus varied with practice setting, from $500 to $1500. Lower costs were discovered in high-volume practice settings, indicating that a shift to increased use of ceramic femoral heads would likely decrease ceramic surplus for most institutions.

We used a series of simulations to predict maximum ceramic surplus after manipulation of theoretical incidence ratios. The main limitation of this study was our use of 7% as the incidence of painful THA within 1- to 2-year follow-up. This point estimate was derived from a manuscript that to our knowledge provides the most realistic estimate of this complication¹⁰; with use of more complete data in upcoming studies, however, the 7% figure could certainly change. As data are also lacking on the proportion of painful THAs that receive a metal work-up and on the proportion of metal work-ups that indicate revision surgery, we modeled values of 12.5%, 25%, and 50% for each of these metrics to cover a wide range of possibilities.

It is also true the model did not incorporate scenarios to account for the law of unintended consequences, which would caution that using ceramics for all patients may bring a new set of complications. Zirconia ceramic bearings have tended to fracture, with the vast majority of fractures occurring in the liner of ceramic-on-ceramic articulations. Midterm reports and laboratory data suggest this issue has largely been solved with the advent of delta ceramics, a composite containing only a small fraction of zirconia.^19,20 Nevertheless, longer term in vivo data are needed to confirm the stability, longevity, and complication profile of these materials.

A final limitation of the present study is that the cost of a single metal toxicity work-up was based on just one institution. Grossly differing cost structures in other markets could alter the economic risk–benefit analysis we have described. However, we should note that the costs of tests, procedures, and appointments at our institution were uniform across a wide variety of practice settings in multiple regions of the United States, and thus are likely similar to the costs at a majority of practices.

Although our model took some liberties by necessity, it was also quite conservative in many respects. Many patients who undergo surveillance for metal toxicity undergo serial follow-ups; for this analysis, however, we considered the cost of only a single work-up. In addition, our proposed cost of revision surgery accounts only for facility and personnel costs during a 3-day inpatient stay and does not include the costs of implants, perioperative medications and devices, follow-up care, and potentially longer hospital stays or subsequent procedures, all of which can be highly variable and add considerable cost. Had any or all of these factors been incorporated into more complex modeling, the potential economic benefits of ceramic femoral heads would have been significantly greater.

After taking all these factors into account, our model found that maximum ceramic surplus ranged from $488 to $2044, depending on theoretical incidence ratio and imaging modality (Table 3). The lowest maximum ceramic surplus values ($511 for MARS-MRI protocol, $488 for US protocol) were based on the assumption that only 12.5% of patients who present with a painful THA receive a single metal work-up (0.875% of all THAs) and that only 12.5% of those patients are eventually revised (0.11% of all THAs). This outcome suggests ceramic femoral heads could be more cost-effective than cobalt-chrome femoral heads under these conservative projections when considering ceramic surplus is already as low as $500 at some high-volume centers. This figure would likely decline further in parallel with widespread growth in demand. Further study on the epidemiology of trunnionosis, corrosion, and metal toxicity in metal-on-polyethylene THA is needed to evaluate the economic validity of this proposal. Nevertheless, the superior safety profile of ceramic femoral heads with regard to metal toxicity indicates that wholesale use in THAs may in fact provide the most economical option on a societal scale.

Am J Orthop. 2016;45(6):E362-E366. Copyright Frontline Medical Communications Inc. 2016. All rights reserved.

LONDON – Contrary to expectation of a neuroprotective benefit, fluoxetine does not slow down the progressive phase of multiple sclerosis, according to the results of a randomized, double-blind, multicenter trial.

The first results of the FLUOX-PMS trial, reported by Melissa Cambron, MD, of University Hospital Brussels (Belgium), showed no statistically significant difference between fluoxetine and placebo for improving the primary endpoint of the time to confirmed disease progression.

LONDON – Contrary to expectation of a neuroprotective benefit, fluoxetine does not slow down the progressive phase of multiple sclerosis, according to the results of a randomized, double-blind, multicenter trial.

The first results of the FLUOX-PMS trial, reported by Melissa Cambron, MD, of University Hospital Brussels (Belgium), showed no statistically significant difference between fluoxetine and placebo for improving the primary endpoint of the time to confirmed disease progression.

LONDON – Contrary to expectation of a neuroprotective benefit, fluoxetine does not slow down the progressive phase of multiple sclerosis, according to the results of a randomized, double-blind, multicenter trial.

The first results of the FLUOX-PMS trial, reported by Melissa Cambron, MD, of University Hospital Brussels (Belgium), showed no statistically significant difference between fluoxetine and placebo for improving the primary endpoint of the time to confirmed disease progression.