Responsibility for managing musculoskeletal disorders – A cross-sectional postal survey of attitudes

Background: Musculoskeletal disorders are a major burden on individuals, health systems and social care systems and rehabilitation efforts in these disorders are considerable. Self-care is often considered a cost effective treatment alternative owing to limited health care resources. But what are the expectations and attitudes in this question in the general population? The purpose of this study was to describe general attitudes to responsibility for the management of musculoskeletal disorders and to explore associations between attitudes and background variables. Methods: A cross-sectional, postal questionnaire survey was carried out with a random sample of a general adult Swedish population of 1770 persons. Sixty-one percent (n = 1082) responded to the questionnaire and was included for the description of general attitudes towards responsibility for the management of musculoskeletal disorders. For the further analyses of associations to background variables 683–693 individuals could be included. Attitudes were measured by the "Attitudes regarding Responsibility for Musculoskeletal disorders" (ARM) instrument, where responsibility is attributed on four dimensions; to myself, as being out of my hands, to employers or to (medical) professionals. Multiple logistic regression was used to explore associations between attitudes to musculoskeletal disorders and the background variables age, sex, education, physical activity, presence of musculoskeletal disorders, sick leave and whether the person had visited a care provider. Results: A majority of participants had internal views, i.e. showed an attitude of taking personal responsibility for musculoskeletal disorders, and did not place responsibility for the management out of their own hands or to employers. However, attributing shared responsibility between self and medical professionals was also found.The main associations found between attitude towards responsibility for musculoskeletal disorders and investigated background variables were that physical inactivity (OR 2.92–9.20), musculoskeletal disorder related sick leave (OR 2.31–3.07) and no education beyond the compulsory level (OR 3.12–4.76) increased the odds of attributing responsibility externally, i.e placing responsibility on someone or something else.Conclusion: Respondents in this study mainly saw themselves as responsible for managing musculoskeletal disorders. The associated background variables refined this finding and one conclusion is that, to optimise outcome when planning the prevention, treatment and management of these disorders, people's attitudes should be taken into account

Practice guideline for the treatment of patients with eating disorders (revision). American Psychiatric Association Work Group on Eating Disorders.

A. CODING SYSTEM: Each recommendation is identified as falling into one of three categories of endorsement, indicated by a bracketed Roman numeral following the statement. The three categories represent varying levels of clinical confidence regarding the recommendations: [I] recommended with substantial clinical confidence. [II] recommended with moderate clinical confidence. [III] may be recommended on the basis of individual circumstances. B. GENERAL CONSIDERATIONS: Patients with eating disorders display a broad range of symptoms that frequently occur along a continuum between those of anorexia nervosa and bulimia nervosa. The care of patients with eating disorders involves a comprehensive array of approaches. These guidelines contain the clinical factors that need to be considered when treating a patient with anorexia nervosa or bulimia nervosa. 1. Choosing a site of treatment: Pretreatment evaluation of the patient with an eating disorder is essential for determining the appropriate setting of treatment. The most important physical parameters that affect this decision are weight and cardiac and metabolic status [I]. Patients should be psychiatrically hospitalized before they become medically unstable (i.e., display abnormal vital signs) [I]. The decision to hospitalize should be based on psychiatric, behavioral, and general medical factors [I]. These include rapid or persistent decline in oral intake and decline in weight despite outpatient or partial hospitalization interventions, the presence of additional stressors that interfere with the patient's ability to eat (e.g., intercurrent viral illnesses), prior knowledge of weight at which instability is likely to occur, or comorbid psychiatric problems that merit hospitalization. Most patients with uncomplicated bulimia nervosa do not require hospitalization. However, the indications for hospitalization for these patients can include severe disabling symptoms that have not responded to outpatient treatment, serious concurrent general medical problems (e.g., metabolic abnormalities, hematemesis, vital sign changes, and the appearance of uncontrolled vomiting), suicidality, psychiatric disturbances that warrant hospitalization independent of the eating disorders diagnosis, or severe concurrent alcohol or drug abuse. Decisions to hospitalize on a psychiatric versus a general medical or adolescent/pediatric unit depend on the patient's general medical status, the skills and abilities of local psychiatric and general medical staffs, and the availability of suitable intensive outpatient, partial and day hospitalization, and aftercare programs to care for the patient's general medical and psychiatric problems. 2. Psychiatric management: Psychiatric management forms the foundation of treatment for patients with eating disorders and should be instituted for all patients in combination with other specific treatment modalities. Important components of psychiatric management for patients with eating disorders are as follows: establish and maintain a therapeutic alliance; coordinate care and collaborate with other clinicians; assess and monitor eating disorder symptoms and behaviors; assess and monitor the patient's general medical condition; assess and monitor the patient's psychiatric status and safety; and provide family assessment and treatment [I]. 3. Choice of specific treatments for anorexia nervosa: The aims of treatment for patients with anorexia nervosa are to 1) restore patients to healthy weight (at which means and normal ovulation in females, normal sexual drive and hormone levels in males, and normal physical and sexual growth and development in children and adolescents are restored); 2) treat physical complications; 3) enhance patients' motivations to cooperate in the restoration of healthy eating patterns and to participate in treatment; 4) provide education regarding healthy nutrition and eating patterns; 5) correct core maladaptive thoughts, attitudes, and feelings related to the eating disorder; 6) treat associated psychiatric conditions, including defects in mood regulation, self-esteem, and behavior; 7) enlist family support and provide family counseling and therapy where appropriate; and 8) prevent relapse. a. Nutritional rehabilitation: A program of nutritional rehabilitation should be established for all patients who are significantly underweight [I]. Nutritional rehabilitation programs should establish healthy target weights and have expected rates of controlled weight gain (e.g., 2-3 lb/week for most inpatient and 0.5-1 lb/week for most outpatient programs). Intake levels should usually start at 30-40 kcal/kg per day (approximately 1000-1600 kcal/day) and should be advanced progressively. During the weight gain phase, this may be increased to as high as 70-100 kcal/kg per day. During weight maintenance and for ongoing growth and development in children and adolescents, intake levels should be 40-60 kcal/kg per day. Patients who require higher caloric intakes may be discarding food, vomiting, or exercising frequently or have more nonexercise motor activity (e.g., fidgeting); others may have a truly higher metabolic rate. Patients also benefit from vitamin and mineral supplements (and in particular may require phosphorus before serum hypophosphatemia occurs). Medical monitoring during refeeding is essential [I]. It should include assessment of vital signs as well as food and fluid intake and output; monitoring of electrolytes (including phosphorus); and observation for edema, rapid weight gain (associated primarily with fluid overload), congestive heart failure, and gastrointestinal symptoms, particularly constipation and bloating. For children and adolescents who are severely malnourished (weight <70% of the standard body weight), cardiac monitoring may be useful, especially at night. Physical activity should be adapted to the food intake and energy expenditure of the patient. Nutritional rehabilitation programs should also include helping patients deal with their concerns about weight gain and body image changes, educating them about the risks of their eating disorder, and providing ongoing support to patients and their families [I]. b. Psychosocial interventions: The establishment and maintenance of a psychotherapeutically informed relationship is beneficial [II]. Once weight gain has started, formal psychotherapy may be very helpful. There is no clear evidence that any specific form of psychotherapy is superior for all patients. Psychosocial interventions need to be informed by understanding psychodynamic conflicts, cognitive development, psychological defenses, and complexity of family relationships as well as the presence of other psychiatric disorders. Psychotherapy alone is generally not sufficient to treat severely malnourished patients with anorexia nervosa. Ongoing treatment with individual psychotherapeutic interventions is usually required for at least a year and may take 5-6 years because of the enduring nature of many of the psychopathologic features of anorexia nervosa and the need for support during recovery. Family therapy and couples psychotherapy are frequently useful for the alleviation of both the symptoms of the eating disorder and the problems in familial relationships that may be contributing to the maintenance of these disorders [II]. Group psychotherapy is sometimes used as an adjunctive treatment for anorexia nervosa, but caution must be taken that patients do not compete to be the thinnest or sickest patient or become excessively demoralized through bearing witness to the difficult, ongoing struggles of other patients in the group. c. Medications: Psychotropic medications should not be used as the sole or primary treatment for anorexia nervosa [I]. The role for antidepressants is usually best assessed following weight gain, when the psychological effects of malnutrition are resolving. These medications should be considered for the prevention of relapse among weight-restored patients or to treat associated features of anorexia nervosa, such as depression or obsessive-compulsive problems [II]. 4. Choice of specific treatments for bulimia nervosa: a. Nutritional rehabilitation/counseling: Nutritional counseling as an adjunct to other treatment modalities may be useful for reducing behaviors related to the eating disorder, minimizing food restriction, increasing the variety of foods eaten, and encouraging healthy but not excessive exercise patterns [I]. b. Psychosocial interventions: Psychosocial interventions should be chosen on the basis of a comprehensive evaluation of the individual patient, considering cognitive and psychological development, psychodynamic issues, cognitive style, comorbid psychopathology, patient preferences, and family situation [I]. Cognitive behavioral psychotherapy is the psychosocial treatment for which the most evidence for efficacy currently exists, but controlled trials have also shown interpersonal psychotherapy to be very useful. Behavioral techniques (e.g., planned meals, self-monitoring) may also be helpful. Clinical reports have indicated that psychodynamic and psychoanalytic approaches in individual or group format may be useful once bingeing and purging are improving. Patients with concurrent anorexia nervosa or severe personality disorders may benefit from extended psychotherapy. Family therapy should be considered whenever possible, especially for adolescents still living with parents or older patients with ongoing conflicted interactions with parents [II]