Gastric Banding (The LAP-BAND System)

The LAP-BAND System, otherwise known as Lap Band or Lapband, is a device that can be placed around the first part of the stomach during "key-hole" (laparoscopic) surgery for weight loss. The device is actually an adjustable band made of flexible, silicone material. A thin tube connects the band to a port placed under the abdominal skin at the time of surgery. The port allows a surgeon to inflate or deflate the band around the stomach without further surgery, and hence maximise a person's weight loss following the procedure.

The LAP-BAND System (Lap Band) works by forming a small pouch before food passes into the main stomach. This pouch holds less solid food than the stomach, so it makes the person feel “full” earlier. Food in the pouch is emptied more slowly than from the stomach, so the person may also feel “full” for longer following a meal.

The effectiveness of the system does require modification of a person's diet. In particular, high-energy drinks (such as protein shakes, smoothies, meal replacements) should be avoided because they pass straight through the small pouch and do not cause the sense of fullness that leads to weight loss.

There are a number of factors to consider when deciding if this procedure is appropriate. The major indication for laparoscopic banding surgery is for morbidly obese patients to lose weight. The following are some of the main criteria are used to assess if the LAP-BAND System (Lap Band) is appropriate:

 

The LAP-BAND System has been shown to effectively cause weight loss in morbidly obese patients. The average patient will lose 87% of their excess weight after having the LAP-BAND System inserted. This should be compared to a person trying to lose weight by diet, exercise and medication therapy – where the average person will only lose 21% of their excess weight.

Large studies have shown that the average person will lose 23kg following this surgery at 2 years, and up to 43kg at 5 years post-operatively.

The major benefit of the LAP-BAND System is weight loss. It has been used effectively in Australia since 1994. The operation to insert the LAP-BAND System is called gastric banding surgery. This surgery is the simplest of all types of surgery performed for obesity. It is also considered the safest surgery for weight loss. In most cases, patients who have this surgery will only be in hospital for 24 hours.

Following the surgery, a number of other medical problems will be improved in conjunction with weight loss. Studies of patients who have received gastric banding surgery show improvements in the following diseases after 2 years:

Laparoscopic gastric banding surgery for the placement of the LAP-BAND System is a complex procedure. Despite this, the overall rate of complication is low. Every type of surgery carries risk. The risk of death within 30 days of this procedure is very low – less than 0.5%.

The main problems that may occur after surgery are infection (of the wound or the lungs), blood clots (in the legs or lungs) and collapse of the lungs (from the anaesthetic).

There are some specific problems that may occur following gastric banding surgery. In 5 – 10% of patients the band may slip downwards or the pouch of the stomach may dilate. In these situations, another operation is required to adjust the band position. In less than 2% of patients the band may erode into the lining of the stomach. This is a serious complication but is uncommon.

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The formula for calculating your body mass index is:
BMI = weight (kilograms) / (height (metres) * height (metres))

For example:
A man who weighs 85 kilograms and is 1.8 metres tall would have a BMI of
BMI = 85 / (1.8 * 1.8)
BMI = 85 / 3.24
BMI = 26.2

This information will be collected for educational purposes, however it will remain anonymous.

   Kral J. ABC of Obesity: Management: Part III – Surgery [5th article in series] British Medical Journal. 2006; 333; 900-3. Available online [http://www.bmj.com]Sjorstom L, Lindroos A, Peltonen M, Torgson J, Bouchard C, Carlsson B, et al Lifestyle, diabtes and cardiovascular risk factors 10 years after bariatric surgery. New England Journal of Medicine. 2004; 351(26): 2683-93.O’Brien P. (2007) The LAP-BAND Solution – A partnership for weight loss.Northern Rivers General Practice Network (cited 12th December 2007) What GPs should know about lap banding. Available online [http://www.medicineau.net.au/clinical/obesity/obesit3160.html]Allergan Australia (2007) About laparoscopic gastric banding [cited 11th December 2007] Available online [http://www.gastricbandingsurgery.com.au/about_gastric_banding.php]Wilkinson, S. (cited December 21st 2007) Obesity Surgery: Lap-Band Surgery, Am I a suitable candidate? Available online: [http://www.tasmaniaobesitysurgery.com.au/lapband.html]National Health and Medical Research Council (2003) Clinical Practice Guidelines for the management of overweight and obesity in Australia [update 19th March 2004] Commonwealth of Australia, Department of Health and Ageing [Available online: www.obesityguidelines.gov.au ]O’Brien P. Treatment of mild to moderate obesity with laparoscopic adjustable banding or an intensive medical program: a randomized trial. Annals of Internal Medicine. 2006; 144(9): 625-33.Colquitt, J. Clegg, A. Loveman, E. Royle, P. Sidhu, M. (2005) Surgery for morbid obesity. [Cochrane clinical review] Available online: [http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD003641/frame.html]Morris, P. Wood, W. (2000) [2nd edition] Oxford textbook of Surgery: Chapter 25; Surgery for Obesity [chapter author Grace, M.] Oxford University Press: Oxford.Allergan Australia (2007) About laparoscopic gastric banding [cited 11th December 2007] Available online [http://www.gastricbandingsurgery.com.au/about_gastric_banding.php]Allergan Australia (2003) LAP-BAND Data Sheet.

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Clinical Trials

Click here to watch a video on drug trialling.

A clinical trial is a scientifically constructed investigation of a treatment (e.g. medication) that involves patient volunteers. Some clinical trials involve a mixture of healthy people and patients in the study group. Clinical trials are the final stage of medication (drug) research in the treatment of many diseases. They may also be conducted on new procedures (e.g. imaging scans). Clinical trials test new approaches to preventing disease, new techniques of screening for early detection of diseases (e.g. cancers), new tests to diagnose known diseases, new treatments (e.g. drugs), genetic studies, and also new approaches to managing end-of-life care for terminally ill patients. For many patients, clinical trials are an important step in accessing newly discovered therapies before they become generally available. It is important to be well informed about the risks and benefits of any treatment before starting.

Click here to watch a video on the importance of clinical trials.

Click here to watch a video on gastrointestinal cancers and clinical research.

Clinical trials are used throughout medicine to improve treatments available to patients. Scientists use laboratory and animal studies to help them to understand diseases and develop new treatment ideas. But for a new drug to be used routinely in people, the effect of new or different treatments on patients and healthy persons must be known. Clinical trials are also needed to determine the correct dose of a new medication, to determine whether the drug will treat the disease effectively in humans, the safety of a new drug alone and in combination with other therapies, and to determine whether a new treatment is better than standard treatment. Clinical trials are one requirement for a new drug to become licensed by the Therapeutic Goods Administration (TGA) in Australia. Without registration, a treatment cannot be provided under the Medicare health scheme.

Clinical trials allow access to new medications and treatments before they would otherwise be widely available. If the drug is effective, those enrolled in trials will be among the first to benefit. Being a participant in a clinical trial also improves the understanding and knowledge of many conditions, and has the potential to benefit future suffers of your disease. When you are an enrolled participant in a clinical trial, your health care is provided by a leading physician in that field (e.g. a consultant or an experienced, senior registrar). This allows close monitoring of any side effects of the treatment, limits any potential problems, and allows early recognition of problems. It also ensures that you receive the best available care and monitoring while you are involved. There is some evidence that suggests cancer patients who are involved in clinical trials have a better outcome than those who are not.

A clinical trial will involve new medications or treatments for which not all the side effects and risks are known. The doctors may not be able to predict all the side effects that may occur. Sometimes the effectiveness of a new treatment will not be fully known until there are clinical trials. For this reason, new drugs may not always work, or they may be less effective than the current standard treatment. Patients must also consider that this treatment may work for some people, but not necessarily for them. Research also continues to determine why some treatments work in some people and not in others.

There are a number of stages of development that occur before a medication is trialled in humans (clinical trial). Early steps in drug development occur in a laboratory where individual cells can be examined under a microscope and the effects of the medication can be monitored. If a medication is thought to have the desired effects, it may then be tested on animals. If there are little or no adverse effects and the medication is shown to be effective, then drug companies can apply for testing in humans. Human testing is the final stage in the drug's development. A drug will only reached this stage if it has shown promising results in laboratory and animal studies, and there are no known serious side effects for humans.

Clinical trials in humans are divided into 4 phases.
Phase I trials: The first part of development. The aim of this trial is to determine if the treatment is safe, what the expected side effects are, and to determine a dose for the treatment. These are usually only conducted with a small number of healthy volunteers. The trials usually last a few weeks to months.

Phase II trials: The aim of these trials is to establish how well a treatment works. These trials are usually conducted with a small number of supervised patients. Specialists in the field of the disease will monitor the patients and review their progress regularly.

Phase III trials: These trials involve a larger number of patients. Their aim is to show whether or not a new treatment is better than the current standard treatment. The trial involves 2 groups: one group of patients will get the standard treatment, and the other group will get the newer treatment. It is usual for the patient and the doctor not to know which of these treatments the patient is receiving. Because the trials involve a larger number of patients, this study also gives a better understanding of the potential side effects of the new treatment.

Phase IV trials: Continued research undertaken after the treatment is marketed and introduced as part of standard therapy. The aim of these trials is long-term surveillance of the treatment. Many thousands of patients are usually enrolled in phase IV trials.

United States National Institute of Health Services (cited December 9th 2007) Understanding Clinical Trials [Available online: http://www.clinicaltrials.gov/ct2/info/understand] (last updated 20th September 2007) Medicines Australia (cited November 31st, 2007) Clinical Trials [Available online: http://www.medicinesaustralia.com.au] Department of Health and Aging; Therapeutic Goods Administration (cited 9th December 2007) The Australian Clinical Trial Handbook [Available online: http://www.tga.gov.au/ct/cthandbook.pdf] National Cancer Institute (cited 9th December 2007) Clinical Trials: What is a clinical trial? [Available online: http://www.cancer.gov/clinicaltrials/learning/what-is-a-clinical-trial] (last updated 24th March 2006) Mills N, Donovan J, Smith M, Jacoby A, Neal D, Hamdy F. Perceptions of equipoise are crucial to trial participation: a qualitative study of men in the ProtecT study. Controlled Clinical Trials 2003; 24(3): 272-82. Freedman B. Equipoise and the ethics of clinical research. New England Journal of Medicine 1987; 317(3): 141-5. Styker J, Wray R, Emmons K, Winer E, Demetri G. Understanding the decisions of cancer clinical trial participants to enter research studies: factors associated with informed consent, patient satisfaction and decisional regret. Patient Education and Counselling 2006; 63(1-2): 104-9. National Cancer Institute (cited 9th December 2007) Clinical Trials: A guide to understanding informed consent [Available online: http://www.cancer.gov/clinicaltrials/learning/what-is-a-clinical-trial] (last updated 23rd December 2003) Strevel E, Newman C, Pond G, MacLean M, Siu L. The impact of an educational DVD on cancer patients considering participation in a phase I clinical trial. Supportive Care in Cancer 2007; 15(7): 829-40. Wray R, Stryker J, Winer E, Demetri G, Emmons K. Do cancer patients fully understand clinical trial participation? A pilot study to assess informed consent and patient expectations. Journal of Cancer Education 2007; 22(1): 21-4.

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Pain

Pain is an unpleasant sensory and emotional experience common to many different diseases. It can be caused by damage to tissues, or by damage to nerve cells and pathways. For more information about the mechanisms and different types of pain, see the anatomy and physiology of pain. Most diseases are associated with some degree of pain. For more specific information about pain in different areas of the body, see:

If you visit your health practitioner complaining of pain, he or she will ask a number of questions about the quality and location of the pain. This may help to identify the cause of pain. Questions may include:

Site: The exact location of the pain should be determined. In many cases, pointing to the site of worst pain is helpful. Is the pain well or poorly localised? Radiation: Any radiation of pain (e.g. pain which is felt mostly in one place, but which "goes through" to another) may be characteristic of certain diseases. Onset and offset: Did the pain develop acutely? Is it continuously present or intermittent? Was the onset of pain associated with any identifiable event, such as the onset of back pain while lifting something heavy? Quality: Descriptions such as sharp, dull, stabbing, cramp-like (colicky) or burning may help to characterise the pain as being directly due to tissue damage, or due to nerve damage (known as neuropathic pain). Severity: This may be recorded on a scale of one to ten, where ten is the worst pain possible. It is also important to discuss whether the pain interferes with sleep or normal daily activities. Aggravating and relieving factors: Do certain positions make the pain better or worse? Has any pain-relieving medication been tried, and was it effective? Associated symptoms: Including nausea and vomiting, muscle weakness etc.

Your health practitioner will then need to examine you. The type of examination will depend on the location and type of pain.

The tests performed will depend on the location and type of pain. They may include blood tests such as full blood picture or imaging tests such as x-ray, CT scans, ultrasound or MRI. Patients with chronic pain may be asked to complete specialised pain questionnaires such as the Pain Disability Index or McGill Pain Questionnaire. These are designed to assess the level of pain and the degree to which pain impairs functional abilities.

Pain management is a complex subject. Depending on the cause, type and location of pain, a different treatment strategy will be needed. Some pain will be self-limiting (meaning it will go away by itself), and need pain-relief medications only temporarily or not at all; whereas chronic pain may last years, be resistant to most of the normal pain treatment options, and require a more holistic (whole-person) approach. Management of chronic pain is best managed with a multidisciplinary approach. Some of the different methods that may be used are discussed below.

Analgesics

The World Health Organisation (WHO) groups analgesics for the management of severe, chronic pain into three groups:

Non-opioid drugs: Simple analgesics, including paracetamol, aspirin and non-steroidal antiinflammatory drugsWeak opioid drugs: Include codeine and dextropropoxypheneStrong opioid drugs: Include fentanyl (Durogesic), morphine (Kapanol), methadone and buprenorphine

One or more of these agents may be required to achieve pain control. The approach should be individualised according to patient requirements.

Co-analgesics

Co-analgesic medications are those which are not specifically designed to relieve pain, but which can help improve pain either alone or in combination with other medications. They are often particularly useful in the management of neuropathic pain. Examples of some co-analgesic drugs include:

Psychological and social aspects

Depression is a common problem in patients with chronic pain. It is a serious condition which requires treatment. Managing depression appropriately can also improve perception of pain.

Behavioural approaches

Behavioural approaches include relaxation techniques, hypnotic techniques, biofeedback and cognitive-behavioural therapy. They have all been shown to reduce pain intensity and improve long-term functioning in patients with chronic pain. These methods should generally be used as part of an integrated multidisciplinary approach.

For information about the management of pain in children, see paediatric pain management.

Ashburn MA, Staats PS. Management of chronic pain. Lancet. 1999;353(9167):1865-9. [Abstract]Braunwald E, Fauci AS, Kasper DL, et al. Harrison's Principles of Internal Medicine (16th edition). New York: McGraw-Hill Publishing; 2005. [Publisher]Jones JB. Pathophysiology of acute pain: Implications for clinical management. Emerg Med (Fremantle). 2001;13(3):288-92. [Abstract]Kumar P, Clark M (eds). Clinical Medicine (6th edition). Edinburgh: WB Saunders Company; 2005. [Publisher] Murtagh J. General Practice (3rd edition). New York: McGraw-Hill; 2003. [Publisher]Talley NJ, O'Connor S. Clinical Examination: A Systematic Guide to Physical Diagnosis (4th edition). Eastgardens, NSW: MacLennan & Petty; 2001. [Publisher]

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LDL (Low Density Lipoprotein) Cholesterol Lowering

 

LDL cholesterol lowering drugs are commonly prescribed to people with high levels of LDL (low density lipoprotein) cholesterol.

When too much LDL cholesterol is present in the blood, it can begin to build up in the inner walls of the arteries that feed the heart and brain. Together with other substances, it can form atherosclerotic plaques, a sort of thick, hard deposit that can clog arteries and lead to problems such as coronary heart disease and stroke.

Previous research has demonstrated that lowering LDL cholesterol reduces the progression of heart disease and death rate.   

Cholesterol is a waxy, fat-like substance that is naturally found in the body's cell walls. The level of cholesterol in the body is determined by two things: the amount of cholesterol that we absorb in our intestines, and the amount that we produce in our liver. Having some cholesterol in the body is normal and healthy - we need it to produce certain hormones, vitamin D, and bile acids that help to digest fat.

If we have too much cholesterol, it can build up in arteries and lead to coronary heart disease and many other serious conditions. There are two major types of cholesterol found in the blood: low-density lipoprotein (LDL) cholesterol, sometimes referred to as 'bad' cholesterol, and high density lipoprotein (HDL) cholesterol, or 'good' cholesterol.

LDL cholesterol is called 'bad' because it is a major contributor to the development of atherosclerosis - the sticky plaques that can form inside blood vessels and contribute to problems like stroke. HDL cholesterol is 'good' because it helps remove cholesterol from these developing plaques, taking it back to the liver to be excreted from the body in bile. Levels of HDL in the body can be raised by things like exercise, and lowered by smoking.

Why lower LDL cholesterol?

Lowering LDL cholesterol levels in the blood can have a number of positive effects for your health, including: Reducing the number and extent of sticky cholesterol plaques on artery walls; Stopping existing plaques from rupturing, which can cause problems with formation of blood clots; Decreasing the risk of developing problems such as heart attack and stroke.

This information will be collected for educational purposes, however it will remain anonymous.

  

How can my level of LDL cholesterol be lowered?

Other than drugs, there are a number of lifestyle changes that can be made to help lower LDL cholesterol levels. These include:

Healthy Eating: A low-fat, high fibre diet, staying away from greasy foods and eating more vegetables, can drastically improve cardiac health. For more details and help with regards to diet, see you general practitioner. Fish Oil and Fish: Eating fish twice a week helps to lower cholesterol levels. This can also enhance the effects of medication. Plant Sterols: These can be found in some margarines and help reduce the absorption of cholesterol. Stop Smoking: Stopping smoking is vital to cardiac health as well as overall well-being. It is strongly encouraged that all patients quit smoking. There are various methods for helping with this that can be discussed with your GP. Physical Activity: Moderate to intense physical activity of at least 30 minutes should be undertaken on most, if not all, days. Weight Reduction: While this should come from improved diet and exercise, weight reduction plays an important role in the reduction of LDL cholesterol levels. Alcohol: Alcohol should be drunk in moderation, especially if you have a high level of triglycerides.Salt: Reducing salt intake has been shown to lower high blood pressure, and thus reduce general cardiovascular risk.

Sometimes, though, these lifestyle changes are not enough, and your doctor might prescribe a type of cholesterol-lowering drug to help lower your cholesterol levels.

The most commonly used type of cholesterol-lowering drugs are called statins (sometimes also known as HMG CoA reductase inhibitors). Other drugs used include fibric acid derivatives, bile acid sequestrants, cholesterol absorption inhibitors, and nicotinic acid. These drugs act in different ways, and produce different degrees and types of cholesterol lowering.

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CHD or CHD risk equivalent:
- Coronary heart disease
- Carotid artery disease (symptomatic)
- Peripheral arterial disease
- Abdominal aortic aneurysm
- DiabetesBP >140/90 or on antihypertensivesYounger than 45 for men or 55 for women.45 or older for men or 55 or older for women.

Use the table above to work out how many points you have.

If you have 6 points or over then you are Category 1.

If you scored 2 to 6 points then you are Category 2.

For people who are Category 2 you need to use our Ten year risk tool to work out your Cardiovascular disease ten year risk. If your risk is less than 10% then you are Category 2b. If your risk is 10% or greater then you are Category 2a.

If you scored less than 2 points then you are Category 3.

LDL goal: <100 mg/dL
If your LDL level is greater than this you should consult you local health professional who can give you advice on lifestyle changes and/or medications that may be beneficial.LDL goal: <130 mg/dL
If your LDL level is greater than this you should consult you local health professional who can give you advice on lifestyle changes and/or medications that may be beneficial.LDL goal: <130 mg/dL
If your LDL level is greater than this you should consult you local health professional who can give you advice on lifestyle changes and/or medications that may be beneficial.LDL goal: <160 mg/dL
If your LDL level is greater than this you should consult you local health professional who can give you advice on lifestyle changes and/or medications that may be beneficial.

This information will be collected for educational purposes, however it will remain anonymous.

Many trials have been conducted to look at the benefits for patients of taking cholesterol lowering medications. Some of the results are summarised below:

The Pravastatin or Atorvastatin Evaluation and Infection Therapy-Thrombolysis in Myocardial Infarction 22 (PROVE IT-TIMI 22) trial in Boston compared a high-dose statin treatment to a low-dose statin treatment. The higher dose provided greater protection against death, heart attack, chest pain requiring hospital admission, and stroke; and improved outcomes over two years among patients with acute heart disease. Another group of researchers from the United States showed in their trial, the Treating to New Targets (TNT) trial, that intensive lipid-lowering treatment provides more significant clinical benefit compared with a lower dose of statin drug. The Heart Protection Study in the UK showed that lowering LDL cholesterol from below 3 mmol/L to below 2 mmol/L reduced the risk of heart disease by about one quarter.

Overall, the results of these trials suggest that intensive therapy to lower LDL cholesterol levels is beneficial in treating both acute and stable heart disease. They also suggest that high-risk patients may benefit from more extensive lowering of LDL-cholesterol than was once thought necessary.

For more information on cholesterol, including the health effects of high cholesterol and ways to lower cholesterol levels, as well as some useful tools, see Cholesterol.Brown AS, Bakker-Arkema RG, Yellen L, et al. Treating patients with documented atherosclerosis to National Cholesterol Education Program-recommended low-density-lipoprotein cholesterol goals with atorvastatin, fluvastatin, lovastatin and simvastatin. J Am Coll Cardiol. 1998; 32: 665. Cannon CP, Braunwald E, McCabe CH, et al. Intensive versus moderate lipid lowering with statins after acute coronary syndromes. N Engl J Med. 2004; 350(15): 1495-504. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. Executive summary of the third report of the National Cholesterol Education Program (NCEP) expert panel on detection, evaluation, and treatment of high blood cholesterol in adults (Adult Treatment Panel III). JAMA. 2001; 285: 2486-97. Heart Foundation Australia. Lipid Management Guidelines 2001. Medical Journal of Australia. 2001; 175: S57-S88.Heart Protection Study Collaborative Group. MRC/BHF Heart Protection Study of cholesterol lowering with simvastatin in 20,536 high risk individuals: A randomised placebo-controlled trial. Lancet. 2002; 360: 7-22M. Kastelein JJ, Isaacsohn JL, Ose L, et al. Comparison of effects of simvastatin versus atorvastatin on high-density lipoprotein cholesterol and apolipoprotein A-I levels. Am J Cardiol. 2000; 86: 221. LaRosa JC, Grundy SM, Waters DD, et al. Intensive lipid lowering with atorvastatin in patients with stable coronary disease. N Engl J Med. 2005; 352(14): 1425-34. Ray KK, Cannon CP, McCabe CH, et al. Early and late benefits of high dose atorvastatin in patients with acute coronary syndromes: results from the PROVE IT-TIMI 22 trial. J Am Coll Cardiol. 2005; 46(8): 1405-10. Sacks FM, Tonkin AM, Shepherd J, et al, for the Prospective Pravastatin Pooling Project Investigators Group. Effect of pravastatin on coronary disease events in subgroups defined by coronary risk. Circulation. 2000; 102: 1893.Wood D, De Backer G, Faergeman 0, et al. Prevention of coronary heart disease in clinical practice: recommendations of the Second Joint Task Force of European and other Societies on coronary prevention. Eur Heart. 1998; 19: 1434-503.

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Cognitive-Behavioural Therapy CBT

Cognitive Behavioural Therapy (CBT) is a type of therapy used to treat many different problems, especially psychiatric problems such as depression and anxiety. CBT has its roots in the late 1950s and was officially formed in the late seventies. Since then it has been shown to be a very effective way to help people overcome a variety of problems. CBT is an umbrella term that encompasses many different types of therapy that are all based on the same ideas. The principle is that first there is a thought, this triggers a feeling and this changes a person's actions. The problem is that in many people these thoughts are based on 'incorrect beliefs'. The aim of CBT is to correct these beliefs and this will lead to a change in thoughts leading to a change in feelings and finally a change in behaviour.

CBT is a relatively short-term form of psychotherapy (a type of counselling) that can be used for the treatment of a wide range of psychological disorders including depression, anxiety, eating disorders such as anorexia nervosa, substance abuse and personality disorders amongst others. It can also be used to help people change their lifestyles. It focuses on working on the 'incorrect beliefs' that people have. These 'incorrect beliefs' are usually unintentional but they seriously affect how people react to situations.

CBT is based on the theory a thought or idea must precede a mood, meaning there must be something that a person thinks that leads them to feel a certain way. This, in turn, will lead to the way in which people act. It also says that the way in which people act is heavily influenced by the way that they see themselves and the way that they think others see them.

Below is a simple example.
There are three people (Tom, Dick and Harry) and they all stub their toe on an uneven piece of paving. Tom thinks 'I am such a fool, everyone must think I'm clumsy and stupid'. Tom feels embarrassed and humiliated and quickly returns home.
Dick thinks 'I could have hurt myself, why doesn't the council fix such a hazard'. Dick feels stressed and angry and this reflects on his dealings with everyone he meets that day.
Harry thinks 'Ouch, I hit my toe, but I'm OK' Harry doesn't give it a second thought and it doesn't affect his day. This is a simple example but it illustrates the point.
Tom and Dick both have 'incorrect beliefs' and these beliefs result in thoughts, then feelings (embarrassed and angry) and then actions (Tom goes home while Dick is angry). Only Harry had the right response. He acknowledged that he hurt himself but realised that he was OK and went about his day as normal.

The idea behind CBT is that unwanted behaviours and moods such as depression are often caused by a certain type of thought. These thoughts have usually been held by people for a long time, remaining under the surface. Certain events 'reactivate' these types of thoughts and can cause negative moods and behaviours. These thoughts, when pulled apart and examined, are often based on the illogical ideas and 'false' beliefs that CBT aims to correct. If CBT can correct these false thoughts then in that situation in the future, the person will react differently and see things from a point of view that will not lead to a negative mood.

CBT is usually a relatively short-term treatment, with therapy lasting for up to 6 months. During individual therapy you will meet with your therapist on a regular basis and during these sessions:

At first you will set short, medium and long term goals. The therapist will also spend time on your past life and background.With the therapist, you break each problem down into its separate parts. Your therapist may ask you to keep a diary to help identify your individual thoughts and emotions.Together you will look at your thoughts, feelings and behaviours to work out if they are unrealistic, or unhelpful and how they affect you.The therapist will then help you to work out how to change unhelpful thoughts, feelings and behaviours.It's easy to talk but much harder to actually change. So, after you have identified what you can change, your therapist will recommend 'homework' where you will practise these changes in your everyday life.Then at each meeting you discuss how you've managed since the last session.

In CBT people are asked about some situations and their views about the world. They are asked what situations they feel the most negative in and then asked to try and find out exactly why these situations make them feel that way. People are asked to look really hard at these situations and think whether or not the thoughts that lead them to feeling that way are logical or not. Over time it is hoped that people will be able to think in a way that leads to a more positive outlook and behaviour.

There is also a 'behavioural' aspect to CBT that is especially important early in the treatment. People are often asked to schedule positive experiences and things that they enjoy so that there is always something to look forward to. They are also encouraged to reward positive thinking with enjoyable experiences. There is now a new form of CBT that is computer based. This Computerized Cognitive Behavioural Therapy has been shown to be effective for anxiety and depression and more work is underway to see where else it could be useful. The advantage of computerized behavioural therapy is that it requires fewer resources and therefore has the potential to become more widely available.

CBT is an effective method of treating various types of problems. It is relatively short-term and gives people many skills that can be applied to every situation, even after treatment has finished. CBT is especially effective when combined with pharmacological (drug) treatments because they both work together to improve the symptoms. It has even been shown that CBT can change the way the brain works in much the same way as medications. Even in the absence of drug therapy, or if someone is hesitant to begin drug therapy, CBT alone often provides a good treatment. The people who get the most out of CBT seem to be those that are thoughtful and have the ability to self-reflect on situations and are open to change.

While CBT is actually one of the shorter types of treatment for some people it may still seem too long. Also, it is not a 'cure' for any illness and while it does provide a lot of help, it does not completely remove the symptoms, especially if the person is continually in a stressful environment. There are also some conditions that CBT alone does not work very well for and these may require both drug treatment as well as other types of psychotherapy -of which there are many.

CBT has been shown to be effective in the following conditions. However this list is continually growing as more research is done into the use of CBT.

Below are two examples of how CBT can work in certain situations. Although both are greatly simplified they illustrate the principle of CBT.

You've had a bad day, feel fed up, and so go out shopping. As you walk down the road, your friend, who seems deep in thought, walks by and, apparently, ignores you.
You think: He ignored me, he must not like me, I will ignore him.
You feel: Low, sad, rejected
You Do: Go home, you start ignoring the person, the friendship is over.
This shows several points. Firstly there is the false belief that because your friend didn't see you they don't like you. Then it becomes a 'self fulfilling prophecy' because if you ignore your friend they will become upset and eventually stop being your friend.

CBT will work on changing your assumptions. For example, your friend seemed deep in thought, maybe something has just happened to them? It would be good to get in touch with them to find out if everything is OK. Another example. "Overfilling the swimming pool is the last straw in my relationship with my parents. The whole garden will have to be re-landscaped. The footings may need to be replaced." Here the problem is magnification. The trigger was overfilling the swimming pool, this combined with magnification leads to the thought that the garden is ruined, leading to feelings of anger, leading to an argument with the parents. CBT will try to change this view, if the pool is overfilled it does not mean that the whole garden is ruined, there is no need to feel angry and there is really no reason to argue with the parents.

The American Institute of Cognitive Therapy. Cognitive Therapy, Cognitive Behavioural Therapy [Online]. [Cited 22/09/2007]. Available at URL: http://www.cognitivetherapynyc.com/default.asp?sid=768Sadock BJ, Sadock VA. Pocket Handbook of Clinical Psychiatry. Philadelphia, Lippincott, Williams and Wilkins, 2005.Scott J. Cognitive Therapy of Affective Disorders: a Review. Journal of Affective Disorders. 1996; 37; I - I I.Stuart RJ, Blecke D, Renfrow M. Cognitive Therapy for Depression. American Family Physician. 2006;73:83-6, 93.Parker G, Roy K, Eyers K. Cognitive behavior therapy for depression? Choose horses for courses. The American Journal of Psychiatry. 2003; 160, 5; 825.Timms P (Ed.). Cognitive Behavioural Therapy. Royal College of Psychiatrists 2007.Cavanagh K, Shapiro DA, Berg SV, Swain S etal. The effectiveness of computerized cognitive behavioural therapy in routine care. British Journal of Clinical Psychology 2006; 45: 499-514.Zaretsky AE, Rizvi S, Parikh SV. How Well Do Psychosocial Interventions Work in Bipolar Disorder?. Canadian Journal of Psychiatry 2007; 52(1): 14-22.Roth A, Fonagy P. What works for whom: A critical review of psychotherapy research (2nd ed.). New York: Guilford Press 2004.James A, Soler A,Weatherall R. Cognitive behavioural therapy for anxiety disorders in children and adolescents. Cochrane Database of Systematic Reviews 2005, Issue 4.Jones C, Cormac I, Silveira da Mota Neto JI, Campbell C. Cognitive behaviour therapy for schizophrenia. Cochrane Database of Systematic Reviews 2004, Issue 4. McGurk SR, Mueser KT. Schizophrenia. Lancet. 2004; 363: 2063-72.Shaw K, O'Rourke P, Del Mar C, Kenardy J. Psychological interventions for overweight or obesity. Cochrane Database of Systematic Reviews 2005, Issue 2Feeney GF. Connor JP, Young R, Tucker J, McPherson A. Improvement in measures of psychological distress amongst amphetamine misusers treated with brief cognitive-behavioural therapy (CBT). Addictive Behaviors 2006; 31: 1833-43.McWelschen L, Oppen P, Dekker JM, Bouter LM, etal. The effectiveness of adding cognitive behavioural therapy aimed at changing lifestyle to managed diabetes care for patients with type 2 diabetes: design of a randomised controlled trial. BMC Public Health 2007; 7: 74-84.

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Liposuction

Liposuction is a cosmetic surgery procedure which involves the removal of excess body fat from under the skin from various parts of the body using a cannula and a suction device. The most common areas that are treated are the abdomen, thighs, buttocks, arms and neck. Liposuction is the most popular cosmetic surgery performed worldwide and is usually done to improve the appearance of distorted body shapes and remove pockets of fat that are difficult to eliminate with diet and exercise. It is also known as body contouring as it can be used to contour the chin, neck, cheeks, ankles, calves, and breasts. It should not be considered as a method of weight loss.

The first liposuction procedures were performed in the early 1980s and were done under general anaesthesia, however they were often associated with serious complications and a high risk of death. New treatments have revolutionised liposuction and it is now considered to be a very safe procedure that can be performed in an office environment with minimal recovery time.

There are a number of liposuction techniques that may be used depending on the site and how much fat is to be removed. They include:

tumescent liposuctionwet liposuctionsuperwet liposuctionultrasound assisted liposuctionpower assisted liposuctionlaser assisted liposuction

Tumescent liposuction is the most common type of liposuction. It involves injecting a large amount of fluid (3-4 times the volume of the fat being removed) made up of a salt solution containing a mix of local anaesthetic and epinephrine into the areas before the fat is removed. The anaesthetic numbs the area and the purpose of the epinephrine is to minimise bruising, swelling and blood loss. Injection of the fluid creates space between the muscle and fatty tissue for the cannula. This form of liposuction usually takes longer than others as the fluid must be injected slowly. However it has the fastest recovery time and least amount of complications.

The super-wet technique is similar to tumescent liposuction except that not as much fluid is used, the amount of fluid injected is about equal to the amount of fat to be removed. This technique takes less time however it usually requires sedation with general anaesthesia.

Ultrasound or ultrasonic-assisted liposuction (UAL) is a fairly recent technique introduced in 1996. It involves exposing fat cells to ultrasonic vibrations which supposedly liquefy fat cells, thereby facilitating aspiration.  This can be done internally through the cannula which transmits ultrasound vibrations under the skin, or by external exposure. This technique may be useful in the removal of fat from dense or fibrous areas of the body such as the upper back or male breast tissue. UAL is often used in conjunction with the tumescent technique or in follow-up procedures. Little benefit is achieved from this procedure and it has been associated with cutaneous burns and higher risk of seroma formation.

Power-assisted liposuction (PAL) is a new technology which utilises a motor-driven, reciprocating cannula attached to a standard aspirator. This reduces the workload on the surgeon as it limits the physical movements that must be made. In addition, it allows the surgeon to remove fat more completely in tight areas where forceful cannula movements are difficult because of physical space constraints. This new technology has been shown to have significant benefits over traditional cannulas.

The newest liposuction technique is Laser-assisted liposuction which works by focusing low energy waves from a laser onto the parts of the body that require treatment. This causes the fat cells to weaken and burst. Like UAL this technique can be used in conjunction to other liposuction procedures. This technique has the advantage of producing much less swelling and bruising and hence a faster recovery time.

Liposuction is a cosmetic surgery used to remove localised accumulations of fat that are resistant to diet and exercise. Liposuction is not a weight loss strategy, substitute for exercise or cure for obesity. It also does not have any effect on cellulite or stretch marks.

Generally anyone with good health physically and mentally can have the procedure done however a patient must go through extensive counselling prior to undergoing surgery to ensure they are suitable.

An ideal candidate for liposuction would have:

normal-weight or slightly-overweight with localised pockets of excess fat in certain areasgenerally healthy and doe not have significant medical problemselastic skinrealistic expectationsis over 18age is not a major factor, although older persons with diminished skin elasticity may not have the same results as persons with tighter skinhas tried diet and exercisehas a stable weight and has a regular exercise routinedoes not suffer from diabetes, coagulation disorders, cardiovascular disease or any infectious diseaseis not pregnant

These are only a guide; however patients that fill these criteria will have a more optimal result.

Liposuction is also suitable for the treatment of other conditions such as breast reduction in men, gynecomastia, removal of lipomas and angiolipoma, hematoma evacuation and improving hyperhidrosis of axillae.

Prior to admitting a patient for a liposuction procedure, a medical history, physical examination and psychological assessment must be undertaken.

Liposuction is contraindicated in patients with severe cardiovascular disease, severe coagulation disorders including thrombophilia, and during pregnancy.Patients with any history of the following conditions must receive medical clearance before undergoing liposuction:

bleeding diathesisembolithrombophlebitisinfectious diseasespoor wound healingdiabetes mellitusheart problemshigh blood pressureDiabetesAllergic reactions to medicationsPulmonary problems  Smoking, alcohol, or drug use

Surgery may be performed in an office, an outpatient facility, or a hospital. Usually liposuction of smaller volumes are done as an outpatient while larger volumes require a stay in hospital to monitor fluid levels and if patients are suffering from any other medical conditions. Depending on how many sites will be treated, the surgery time may range from 1-4 hours.

Markings are made on the skin as a guide to where fat is to be removed. Depending on which procedure is used a general anaesthetic is administered, or for the tumescent technique, a fluid consisting of a salt solution or local anaesthetic and epinephrine is injected into the area being liposuctioned. Small incisions are made in the skin through which a cannula is inserted. The cannula is attached to vacuum pump which can suction out the fat cells as the surgeon moves it back and forth. After the fat is removed, small drainage tubes may be inserted which remove any blood and fluid which has accumulated. If a lot of fluid is lost then a blood transfusion or IV fluid replacement may be needed.

Volumes of fat removed should not exceed five litres especially in patients with comorbidities. Generally, removal of larger volumes is associated with a higher risk of complications mainly due to the fact that this requires general anaesthesia as opposed to local anaesthesia.

Following surgery, bandages are applied to stop any bleeding and keep pressure on the area. These usually are left on for about two weeks. Depending on the extent of the surgery and how much fat was removed the patient may be required to stay overnight in hospital.

It must also be determined whether any previous abdominal surgery has been performed and any problems from past surgical procedures that may influence complications.

Medications that affect blood clotting such as aspirin, anti-coagulants, non-steroidal anti-inflammatory agents and vitamin E, as well as other vitamins and herbs must be ceased two weeks prior to surgery. Depending on the extent of the liposuction to be done, the contraceptive pill may have to be ceased as well.

Physical evaluation

An assessment of general physical health is necessary to determine whether a patient is a suitable candidate for surgery. The specific sites that are being considered for liposuction are examined for potential problems. Skin tone and elasticity is assessed as well as the presence of hernias, scarring, cellulite and stretch marks. If patients have poor skin elasticity they are informed that following surgery they may have skin draping which may need further surgical correction.

Psychological assessment

Inquires are made about diet and exercise habits and any history of weight gain and loss as this can affect the long term success of the procedure. Patients are counselled on the limitations and risks associated liposuction. Their expectations are determined to ensure they are realistic and are aware that full results may take up to 12 weeks to be seen. Liposuction does not result in any significant weight loss and patients should also be aware that fat removed may return if excess weight is put on.

Blood tests

Some general blood tests are carried out to ensure potential candidates are in good health. Selection blood tests to be performed depends on the type and extent of the liposuction procedure and the conditions revealed in the history and physical examination. Usually a complete blood cell count with quantitative platelet assessment, prothrombin time, partial thromboplastintime, liver function tests, pregnancy test for women of child bearing age are performed.

Some common minor side effects that can occur which are usually not permanent or life threatening and are a normal consequence of the surgery include:

Bruising which should fade after a few weeksSwelling which should subside gradually over a month or twoScars varying in size depending on the particular procedure but should fade over the weeks. Scarring depends on the individual as it is partly dependent on heredity. In some people it may take up to a year to heal.Pain which should be temporary and can be ontrolled by either over-the-counter medicationNumbness which may persists for a few weeksLimited mobility 

Liposuction is associated with several risks and complications, many of which are rare and are dependant on the extent and type of procedure. As there is no central registry for reporting of these it is difficult to ascertain the likelihoood or frequency of them. It appears that prolonged procedures and aspirate volumes greater than five litres seem to be associated with higher complication rates. Limiting the volume of aspirate and using local rather than general anesthesia can reduce the risk of some of the major complications such as embolism and death.

A national survey of plastic surgeons found that the most common complications were:

contour irregularitiesunplanned hospital admissionsprolonged swelling

Other complications include:

patient dissatisfactionunfavorable aesthetic results- irregularities in the skin surface following excessive or subdermal liposuction asymmetry, dimpling, lumpiness and waviness and skin laxityhyperpigmentationscarring- incisions usually heal however patient can develop hypertrophic scarring following inadvertent injury to overlying skin through superficial liposuction or UALhematomasseromasinfectionsskin burns, particularly in the use of UAL devicesSkin necrosis- superficial liposuction, overzealous subdermal fat thinning, liposuction in areas of prior incision scars, and UAL can result in partial-thickness and full-thickness skin necrosisnecrotizing fasciitiscerebrovascular accident or transient ischemic attackpulmonary thromboembolismpulmonary fat embolismbleeding, especially if large amounts of fat are removedShock if not enough fluid is replaced during the surgeryFluid overloadtransfusion complicationdeep vein thrombosisDrug toxicity, the patient can react to the anaesthetic or epinephrinetoxic shock syndromeNerve damagethoracic and abdominal cavity perforationaortic perforationacute renal failure

Overall revision or re-operative rates range from 5-15%. Rates of serious or fatal complications are in the range of 0.02% to 0.3% and are predominantly attributed to pulmonary embolus, fat embolus, abdominal perforation, anesthesia.

Following surgery compression garments are applied to the areas that have been treated to reduce swelling and support the skin as it readjusts to the new contour. These usually need to be left on for 2-3 weeks. There is likely to be swelling, bruising, pain and numbness for a few weeks after surgery. Pain medication can be prescribed as well as antibiotics to prevent infection.

Patients can return to work and resume their normal activities within a few days after the procedure. Strenuous excercise should be avoided however walking soon after surgery is advised to prevent blood clots. It may take up to 3-6 months to see the final result of the surgery as swelling subsides and skin contraction occurs. The final outcome generally depends on age, skin elasticity, volume of fat removed and the area it is removed from, with the best results are generally seen in younger patients of normal weight and who have had a small volume of fat removed. Maintaining a healthy lifestyle with regular excersise all aid in improving the final outcome.

For more information on obesity, health and social issues, and methods of weight loss, as well as some useful tools, see Obesity and Weight Loss.  Coleman WP, Glogau RG, Klein JA, Moy RL, Narins RS, Chuang T, Farmer ER, Lewis CW, Lowery BJ and the Guidelines/Outcomes Committee. Guidelines of care for liposuction. American Academy of Cosmetic Surgery.Flynn TC, Coleman WP, field LM, Klein JA and Hanke CW. History of liposuction. Dermatol Surg.; 2000; 26(6); p. 515-520.http://www.plasticsurgery.org.au/procedures/liposuction.htmlSattler G. Advances in liposuction and fat Transfer. Dermatology Nursing; Apr 2005; 17(2); p. 133-139.Jayashree V and Mysore V. Microcannular tumescent liposuction
Indian Journal of Dermatology. 2007; 73 (6); p. 377-383.Guidelines for Liposuction Surgery. 2006. The American Academy of Cosmetic Surgery.
Available from: http://www.cosmeticsurgery.org/Media/2006 Liposuction Guidelines.pdfKatz BE, Bruck MC, Felnsfield L and Prew KE. Power liposuction: a report on complications. Dermatol Surg; 2003; 29; p. 925–927.Prado A, Andrades P, Danilla S, Leniz P, Castillo P and Gaete F. A prospective, randomized, double-blind, controlled clinical trial comparing laser-assisted lipoplasty with suction-assisted lipoplasty. Plastic & Reconstructive Surgery. 2006; 118(4); p. 1032-1045.Matarasso A and Hutchinson OHZ. Liposuction. JAMA. 2001; 285(3); p. 266-268.Flynn TC and Narins S. Preoperative evaluation of the liposuction patient. Dermatologic Clinics. 1999; 17(4); p.729-734.Cowles RA. Liposuction. Updated 5/3/2007 http://www.nlm.nih.gov/medlineplus/ency/article/002985.htm updated 5/3/07

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Blood Pressure Calculator

Normal
Your blood pressure should be rechecked within 2 years or earlier depending on your risk of developing cardiovascular disease. Your General Practitioner can advise you about this risk and also on lifestyle risk reduction.High-Normal
Your blood pressure is elevated. It should be rechecked within 12 months or earlier depending on your risk of developing cardiovascular disease. Your General Practitioner can advise you about this risk and also on lifestyle risk reduction.Grade 1 (mild) Hypertension
Your blood pressure is elevated. It should be confirmed within 2 months. Your General Practitioner should advise you about lifestyle risk reduction and/or medication to lower your blood pressure.Grade 2 (moderate) Hypertension
Your blood pressure is elevated. It should be confirmed within 1 month and you may also need to see a specialist in this time. Your General Practitioner can advise you about lifestyle risk reduction and/or medication to lower your blood pressure.Grade 3 (severe) Hypertension
Your blood pressure is elevated. It should be confirmed within 1 week and you may also need to see a specialist in this time. Your General Practitioner can advise you about lifestyle risk reduction and/or medication to lower your blood pressure.Isolated systolic hypertension
Your systolic blood pressure is elevated. Depending on the level it needs to be confirmed within a certain time (140-159mmHg - 2 months; 160-179mmHg - 1 month; >180mmHg - 1-7 days).You may also need to see a specialist. Your General Practitioner can advise you about lifestyle risk reduction and/or medication to lower your blood pressure.Isolated systolic hypertension with widened pulse pressure
Your blood pressure is elevated. It should be confirmed within 1 week and you may also need to see a specialist in this time. Your General Practitioner can advise you about lifestyle risk reduction and/or medication to lower your blood pressure.Hypotension
Your blood pressure is lower than normal. Your General Practitioner will ask you about symptoms that you may be experiencing and determine if you require treatment or further investigation.

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This information will be collected for educational purposes, however it will remain anonymous.

For more information on blood, blood types, blood tests, and blood donation and transfusion, see Blood.

For more information on high blood pressure, including investigations and treatments, as well as some useful animations, videos and tools, see Hypertension (High Blood Pressure).  

Created: 24/2/2010


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Exercise: Cardio Training

Cardio training is a form of exercise that makes the heart beat a little faster. This includes walking, running, football and tennis. Dr Joe Kosterich talks about the purpose of cardio training, the importance of exercise, and the need to start small.

When people think of exercise, the one that generally comes to mind is cardio training. Cardio training is short for cardiovascular training, so it's a form of exercise that causes our heart to beat a little bit faster, causes the blood to pump around, and gets us to breathe a little bit more quickly.

Obvious sorts of cardio training are walking, running, bike riding and swimming. Most sports, with the exception of things like weight lifting and rifle shooting, are cardio type exercises. So football, cricket, tennis and even golf, to a degree, are all cardio type exercises and sports.

Cardio training is really, really important as the heart is an important part of the body. The brain is really important as well, but you probably hear a lot more about heart attacks than most other forms of diseases. And like most parts of the body, if you use it in the right way and look after it, it will keep you going for longer.

So with cardio training, what are we trying to do? We're trying to get the heart a little bit stronger and more resilient. How do we do that? By basically stressing it a little bit - stressing it to the degree that we get it to work a little bit harder. It's always those last two reps or that last 50 metres that pushes you that little bit further. So in looking to build up a cardio regimen, we're looking to improve our stamina, fitness and overall energy capabilities. This happens gradually. Nobody who's run a marathon has ever gone out and done it the first day - they've built it up over time. Swimmers who excel at 1,500 metres haven't started doing that the first day - they probably started at 25 or 50 metres.

So for those of you who haven't been doing much exercise, you need to start at a small level. For some of you who haven't done exercise for a long time, you may want to check with your doctor and have a little bit of a check-up before starting out. But for most people, if you start out at a low level, away you can go.

Walking is a really good form of exercise. You don't have to raise a major sweat, but you do want to be walking at a pace that is a little bit quicker than just ambling to the letter box. Power walking was very popular for a while and is still a reasonable form of exercise, but just walking itself hits all the buttons in terms of cardio exercise.

Other things we spoke of before, jogging and running are quite good as well. Swimming is an excellent form of cardio exercise. For those who don't like walking or running and perhaps have problems with their joints, walking through water is also a very good form of exercise. Bike riding is fine and you can do that out and about, or you can do it on an exercise bike at the gym, or in front of the TV if you're that way inclined. All of these are good forms of exercise. 

Now, a lot of cardio games or sports - like squash, tennis, football, basketball, the list goes on - are good forms of exercise. If you haven't done them for a while, you need to be training for them. There's often been an executive in particular who hasn't played squash for 15 years, decides they want to get fit, tears out on the squash court and suddenly has problems with a heart attack because they haven't done the preparation or the training. So it's really important that if you want to do sports like that, that you do some cardio exercise.  

Start at a low level, at something that's appropriate to you. If you're not quite sure where to start, have a chat to your doctor. A physio or personal trainer may be able to guide you on the exercise specifics, but for almost everybody you can start at a level of comfort and gradually build up. How do you know you're building up? Your walking distance goes further. You can go the same distance as last week and not feel quite as tired - that's the signal to go a little bit further.

For most people, aim for some cardio exercise 3-4 times a week if you can and for a minimum of 30-40 minutes per day. By the end of it, you raise a little bit of a sweat. You don't have to be drenched with sweat if that's not your thing, but you do need to have known that you've done a little bit of work. If you have, that's going to stand your health in a really good stead in general, and your cardiac system (which is your heart) in particular.

For more information on fitness and exercise, including stretches, types of exercise, exercise recovery and exercise with health conditions, as well as some useful videos, see Fitness and Exercise.

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Male Condom

Male condoms are latex or (less commonly) polyurethane sheaths which are put on the erect penis prior to sexual activity. They provide a barrier to the mixing of the partners' sexual fluids during sexual activity. Male condoms are more commonly used than their female counterparts (the female condom) and are usually referred to simply as condoms.

A male condom prevents the male partner's semen from entering their partner's vagina, anus or rectum, and also protects the male partner from coming into contact with a female partner's vaginal fluids or male or female partner's blood (e.g. from abrasions to the rectum which can tear easily during anal intercourse) during anal or vaginal penetration.

As semen and vaginal fluids are the predominate routes by which sexually transmitted infections (STIs) are spread, male condoms play an important role in preventing the spread of STIs, during heterosexual and homosexual intercourse. While condoms are primarily promoted as devices for preventing STIs, they are also an effective method of contraception.

The use of condoms can be traced back to the ancient Egyptians, who used linen sheaths primarily as protection against disease. In the 1500s when syphilis was becoming an epidemic in Europe, the use of linen soaked in a solution of salt and herbs was documented. In the 1700s, condoms made from animal intestines became available but they were very expensive and often reused. The Chinese used oiled silk paper while the Japanese used leather and tortoise shell sheaths. It was not until 1839 and the development of rubber by Charles Goodyear that the first rubber condom was manufactured.

Since the nineteenth century, condoms have been one of the most popular methods of contraception in the world. Condom use as a contraceptive method declined after the advent of the oral contraceptive pill, sterilisation and other contraceptive methods. However, condom use for the prevention of STIs has increased significantly since the discovering in the early 1980s that HIV is sexually transmitted.

The male condom works to prevent pregnancy and STIs because the latex or polyurethane with which it is made cannot be penetrated by sexual fluids. As it creates an impervious barrier, condoms provide protection against pregnancy and the spread of STIs which are transmitted via sexual fluids (e.g. HIV, hepatitis B, chlamydia and gonorrhoea).

While male condoms do protect against some skin to skin content, they do not provide complete anatomical coverage of the genital skin during sexual intercourse. This means they are less effective in preventing STIs transmitted through skin contact (e.g. herpes).

Male condoms are used throughout the world as contraceptive and STI prevention devices. They are used by individuals who wish to prevent pregnancy and/or STI, either with steady or casual partners. More than 12 billion male condoms were distributed in 2007.

In Australia, individuals who are young and those who have sex with casual or non-cohabiting partners are more likely to use condoms than their older counterparts and those individuals who live with their sexual partners. Women who do not use other forms of contraception are also more likely to use condoms.

A recent study in Australia reported that about 7% of people used condoms consistently with regular partners and 40% used them with consistently with casual partners. While condom use in casual relationships is much higher than in steady relationships, it remains strikingly low, given Australia's high prevalence of STIs (more than 50,000 cases of chlamydia were reported in Australia in 2007, and over 4% of Australian men and women report experiencing genital warts in their lifetime).

In order to protect against STIs, condoms should be used at every act of sexual intercourse (including vaginal, anal or oral sex). In order to protect against pregnancy, condoms should be used at every act of vaginal intercourse.

The effectiveness of male condoms depends on the purpose for which they are being used and the extent to which individuals use condoms correctly. While intact latex and polyurethane are completely impenetrable by sexual fluids, condoms may break or slip off during sexual activity, and are therefore not 100% effective.

Condom users should also be informed that, due to the limited anatomical coverage of condoms (they cover only the penis and not external genitalia), they provide much less effective protection against STIs which spread through skin contact (e.g. herpes).

Despite the incorrect use of condoms reducing their effectiveness as a contraceptive or STI prevention device, studies of condom use within sexual partnerships still report fairly high rates of effectiveness.

As a contraceptive device, condoms are typically regarded as being less effective than permanent contraceptive methods (in particular hormonal methods) when user error is taken into account but still provide a high level of protection compared to no contraceptive use. Condoms provide 98% contraceptive protection, when used consistently and correctly.

As an HIV prevention method for heterosexual couples, male condoms have been estimated to be 80% effective when used consistently and 95% effective when used correctly and consistently. These estimates are based on the study of infections in couples who use condoms consistently and where one partner is HIV positive and the other does not have HIV (sero-discordant couples).

While no studies have monitored the incidence of other STIs amongst sero-discordant couples, studies reporting lower incidence of chlamydia and gonorrhoea amongst consistent condoms users suggest that condoms are also effective in preventing these STIs. Condom use also reduces the risk of contracting herpes simplex virus type 2 in females by around 15%.

As condoms are more likely to break or slip off during sexual intercourse if they are used incorrectly, it is important that users are knowledgeable about their proper use. Health professionals should counsel their patients on the importance of correct and consistent use of condoms and other factors which can affect condom efficacy.

Expiry date

Condoms have a limited shelf life and an expiry date will be printed on each condom packet. Users should be advised to check the expiry date prior to use. They should also be advised that exposure to heat reduces the shelf life of condoms, and to discard any condoms that have been exposed to heat (e.g. in a pocket or in sunlight).

Packaging

Condoms come individually wrapped in foil packaging. Users should ensure that the packet is in good condition and has not been opened or damaged. They should open the packet carefully, taking care not to tear the condom with nails or teeth.

Appearance

The condom will be rolled up in the packet. There will be a thick rim and a circle of loose fine rubber.

Disposable

Condoms are designed for single use only. Users should never attempt to use a condom for more than one act of sexual intercourse in which the penis remains erect. If the penis loses its erection during sexual activity, the couple should remove the condom and wait until the penis is erect again, before applying a new condom. Men who suffer from erectile dysfunction may find female condoms more appropriate, as their use is not contingent on an erection.

Applying and using a condom

Wait until the penis is fully erect before attempting to apply a condom.Hold the condom so that the rim can unroll towards you.The closed end of the condom will have a loose, nipple shaped tip. Hold and squeeze the tip between thumb and forefinger to remove any trapped air. This will create a space for the semen to collect.While holding the tip and with the condom still rolled up, place the condom on the head of the penis.Using the free hand, unroll the condom all the way down to the base of the penis. The condom should unroll easily. If it does not, the condom may be on backwards, may be damaged or too old. Discard the condom and use a new one.Lubricant can be put on the condom prior to sexual intercourse if desired although most brands of condoms are already lubricated. The lubricant may wear off during sexual intercourse. If this occurs, it is important to apply additional water based lubricant (not oil based lubricant as this can damage latex) to reduce the chance of the condom breaking. This point is particularly relevant for patients using condoms for protection during anal sex, as, unlike the vagina, the anus has no natural lubricating mechanism.The condom should be removed immediately after ejaculation and while the penis remains erect. The user should hold the condom at the base while withdrawing the penis from the vagina or anus, and carefully withdraw the penis, taking care not to spill any semen.The user should then remove the condom from the penis and tie a knot at the open end to keep the semen inside.Dispose of the condom by wrapping it in tissue and putting it in the bin. Do not flush it down the toilet.

The main reasons that a condom will fail to protect against STIs is because it either breaks or slips off during sexual intercourse. Condoms which become damaged prior to sexual intercourse (e.g. by teeth or fingernails while opening or applying the condom) will also provide inadequate protection. Factors which can increase the risk of slippage or breakage include:

Not holding the condom firmly at the base while the penis is being withdrawn from the vagina;Not completely unrolling the condom onto the penis;Using a condom which has been exposed to heat or sunlight (such as in a car's glove box or individual's pocket) or has passed its expiry date;Using oil based lubricants, as this can weaken latex condoms and cause them to break more easily;Use of some vaginal preparations or drugs at the same time as condoms.

It is also important to highlight to patients that condoms are only effective while they are being worn. If genital contact occurs prior to the application of a condom, there is a risk that STIs will be transmitted through this genital contact, even if the man has not yet ejaculated his semen. Current research indicates that in Australia, one in eight condoms used are not applied until after genital contact has occurred.

For greater protection against pregnancy, condoms can be combined with other forms of contraception such as the pill. They should not be used in conjunction with female condoms.

There are a number of vaginal preparations which may weaken latex condoms and increase the likelihood of a condom breaking. Women should not use latex condoms at the same time as any of the following preparations:

Dalacin V cream (clindamycin hydrochloride). (Metronidazole gel is safe.) Nilstat vaginal cream (nystatin). (Canesten cream (clotrimazole) is safe.) Fungilin (amphotericin) Pro-feme (progesterone) Monistat vaginal (miconazole nitrate) Prevaryl vaginal (econazole nitrate) Ecostatin (econazole) Nizoral cream (ketoconazole) Premarin (oestrogen cream). (Ovestin and Vagifem (oestradiol) are safe.)

If the condom breaks during intercourse, the penis should be withdrawn immediately. If the sexual partners still wish to continue having sex, a new condom should be applied prior to any further genital contact.

As a precautionary measure against unwanted pregnancy, women who experience condom breakage should visit their doctor to get a prescription for an emergency contraception pill which can be used up to 120 hours after intercourse, to reduce the risk of pregnancy.

Patients should also be informed to test for a range of STIs if they experience condom breakage. Many STIs are easily treated with antibiotics once detected. However, as many STIs remain asymptomatic for extended periods of time, leaving them untreated can lead to infertility and other complications.

STI prevention

The male condom is one of only two biomedical devices (the other being the female condom) which provides a high level of protection against a range of STIs in sexually active individuals. Condoms enable individuals who choose to be sexually active, and particularly those who choose to be sexually active with multiple partners, to reduce the risk of adverse health effects associated with sexual activity. They offer a degree of sexual freedom to individuals living in a world characterised by numerous health risks stemming from sexual activity.

Widely and cheaply available

Male condoms are available from most pharmacies, supermarkets and even petrol stations, meaning that they can be accessed most of the time. Unlike most contraceptive methods, users do not require a prescription to purchase condoms. Free condoms are also distributed by many student services and family planning clinics for individuals with budget constraints.

Temporary or permanent use

As condoms are applied immediately prior to sexual intercourse, an individual does not need to plan condom use in advance as they do for many other methods of contraceptives (e.g. hormonal contraceptive pills must be taken for extended periods). When used consistently and correctly, condoms provide a high level of protection against unwanted pregnancy.

Limited side effects

The only known side effect of the male condom is allergic reaction to latex, which occurs in a small proportion of users (estimated 1-3%). On the contrary, many hormonal contraceptive methods produce a wide range of side effects.

Condoms provide a theoretically high level of protection against both pregnancy and STIs, and the side effects of condom use are negligible. While a small proportion of condoms users (1-3%) report an allergic reaction to the latex with which condoms are made of, the allergic symptoms are temporary and there are no other known side effects of use.

There remain however, numerous barriers to the use of male condoms which mean that male condoms are often used inconsistently or not at all, even in situations where individuals are aware that their sexual activity may involve health risks (e.g. sexual activity with unknown partners) if a condom is not used. The key barriers which limit the use of condoms are discussed below.

User satisfaction

While user satisfaction with male condoms is higher than with female condoms, satisfaction remains poor, particularly amongst men. One study found that less than half of women reported the male condom felt "good" or "very good" during sexual intercourse and that women reported their partners were even less likely to be satisfied with the feel of male condoms. Common reasons cited for reduced satisfaction with male condoms is the associated reduction in sensitivity and sexual enjoyment and the disruption to natural sexual activity (i.e. the need to interrupt sexual activity to apply a condom).

Breakage and slippage

Even when used correctly, condoms can break or slip during sexual intercourse. In Australia, some 23.8% of male condom users responding to the Sex in Australia survey reported at least one incident of condom breakage during sexual intercourse in the year prior to the survey, while 18.1% reported at least one incident of a condom slipping off during sexual intercourse. Breakage and slippage was associated with less experience using condoms, indicating that a significant proportion of these failures were induced by user error.

Need for correct and consistent use

To effectively prevent STIs and pregnancy, condoms must be used correctly at every act of sexual intercourse and applied prior to any genital contact. While many Australians use condoms at some point in their life, only 40% use them consistently with casual partners and one in eight condoms are not applied until after genital contact has occurred.

Condom use is less likely when the sexual partners have consumed alcohol at intoxicating levels (according to Australian guidelines- for more information see Alcohol Intoxication).

Reliance on male partner

Condoms are user dependent and rely mainly on the male partner agreeing to use and applying the condom correctly (despite the female partner being at higher risk of STI and bearing most of the responsibility for unwanted pregnancy).

Condoms are available in variety of sizes, shapes, textures, colours and flavours to suit personal preference. The majority of condoms available are made of latex rubber.

Polyurethane condoms known as Duran (brand name: Avanti) were introduced to the market in the mid-1990s. They provided an alternative for those who were allergic to latex or who did not like the feel and reduced sensitivity that latex condoms produced.

In comparing latex to non-latex condoms, a large proportion of people appear to prefer polyurethane condoms. Polyurethane condoms are thinner, conduct heat better than latex and are less restrictive around the glans of the penis, therefore increasing sensitivity. Users report that the polyurethane condom has a more natural feel, look and smell than latex. Polyurethane is more durable than latex in that it can withstand exposure to heat and is suitable for use with oil or water based lubricants. One study reported no significant differences in the rate of breakage or slippage between latex and polyurethane male condoms.

Male condoms provide effective protection against STIs and pregnancy when they are worn correctly and consistently.Male condoms must be applied prior to every act of vaginal, anal or oral sex to provide protection.Male condoms should be applied to a fully erect penis, prior to any genital contact.A new condom should be applied if the condom slips or breaks.For more information on different types of contraception, male anatomy and related health issues, see Contraception.Padian NS, Buvé A, Balkus J, Serwadda D, Cates W Jr. Biomedical interventions to prevent HIV infection: Evidence, challenges, and way forward. Lancet. 2008; 372(9638): 585-99.Family Planning NSW. Male condom fact sheet [online]. 31 March 2008 [cited 1 March 2009]. Available from URL: http://www.fpnsw.org.au/ fs.020_male_condom08.pdf Centres for Disease Control and Prevention. Male latex condoms and sexually transmitted disease: Fact sheet for public health personnel [online]. 16 December 2008 [cited 1 March 2009]. Available from URL: http://www.cdc.gov/ condomeffectiveness/ latex.htm de Visser RO, Smith AM, Rissel CE, Richters J, Grulich AE. Sex in Australia: Experience of condom failure among a representative sample of men. Aust NZ J Public Health. 2003; 27(2): 217-22.Gilliam ML, Derman RJ. Barrier methods of contraception. Obstet Gynecol Clin North Am. 2000; 27(4): 841-58.United Nations Population Fund (UNFPA). Donor support for contraceptives and condoms for STI/HIV prevention 2005 [online]. 22 March 2007 [cited 1 March 2009]. Available from URL: http://www.unfpa.org/ upload/ lib_pub_file/ 681_filename_dsr_2005.pdf  National Centre in HIV Epidemiology and Clinical Research (NCHECR). HIV/AIDS, viral hepatitis and sexually transmissible infections in Australia: Annual surveillance report 2008 [online]. University of New South Wales. 14 September 2008 [cited 1 March 2009]. Available from URL: http://www.nchecr.unsw.edu.au/ NCHECRweb.nsf/ resources/ SurvReports_3/ $file/ ASR2008-revision.pdfGrulich AE, de Visser RO, Smith AM, Rissel CE, Richters J. Sex in Australia: Sexually transmissible infection and blood-borne virus history in a representative sample of adults. Aust NZ J Public Health. 2003; 27(2): 234-41.Macaluso M, Blackwell R, Jamieson DJ, Kulczycki A, Chen MP, Akers R, et al. Efficacy of the male latex condom and of the female polyurethane condom as barriers to semen during intercourse: A randomized clinical trial. Am J Epidemiol. 2007; 166(1): 88-96.World Health Organization. Family planning: A global handbook for providers [online]. 31 August 2007 [cited 20 June 2009]. Available from URL: http://www.who.int/ entity/ reproductivehealth/ publications/ family_planning/ 9780978856304/ en/ index.html Pinkerton SD, Abramson PR. Effectiveness of condoms in preventing HIV transmission. Soc Sci Med. 1997; 44(9): 1303-12.Weller S, Davis K. Condom effectiveness in reducing heterosexual HIV transmission. Cochrane Database Syst Rev. 2002; (1): CD003255.Shlay JC, McClung MW, Patnaik JL, Douglas JM Jr. Comparison of sexually transmitted disease prevalence by reported level of condom use among patients attending an urban sexually transmitted disease clinic. Sex Transm Dis. 2004; 31(3): 154-60.Wald A, Langenberg AG, Link K, Izu AE, Ashley R, Warren T, et al. Effect of condoms on reducing the transmission of herpes simplex virus type 2 from men to women. JAMA. 2001; 285(24): 3100-6.Valappil T, Kelaghan J, Macaluso M, Artz L, Austin H, Fleenor ME, et al. Female condom and male condom failure among women at high risk of sexually transmitted diseases. Sex Transm Dis. 2005; 32(1): 35-43.Farmer L, Everett S. Non-hormonal contraception. Obstet Gynaecol Reprod Med. 2008; 18(2): 33-8. Australian Government Department of Health and Ageing. National sexually transmissible infections strategy 2005-2008 [online]. Commonwealth of Australia. 27 June 2006 [cited 1 March 2009]. Available from URL: http://www.health.gov.au/ internet/ main/ publishing.nsf/ Content/ 0333DF52D0E2F3EDCA25702A0025132F/ $File/ sti_strategy.pdf  Kulczycki A, Kim DJ, Duerr A, Jamieson DJ, Macaluso M. The acceptability of the female and male condom: A randomized crossover trial. Perspect Sex Reprod Health. 2004; 36(3): 114-9. Sheary B, Dayan L. Contraception and sexually transmitted infections. Aust Fam Physician. 2005; 34(10): 869-72.Mantell JE, Dworkin SL, Exner TM, Hoffman S, Smit JA, Susser I. The promises and limitations of female-initiated methods of HIV/STI protection. Soc Sci Med. 2006; 63(8): 1998-2009.Rosenberg MJ, Waugh MS, Solomon HM, Lyszkowski AD. The male polyurethane condom: A review of current knowledge. Contraception. 1996; 53(3): 141-6.

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Spinal Cord Stimulation Devices

Spinal cord stimulation (SCS) is an emerging, minimally invasive procedure used to treat chronic, refractory, neuropathic pain. Neuropathic pain is one of the most difficult medical conditions to treat; it is not the "normal" pain we associate with stubbing a toe or getting a paper cut – this is nocioceptive pain. Neuropathic pain is caused by abnormal nerve signalling in the nervous system and, as a result, commonly does not respond to most pain relief strategies. It is for this reason that SCS is a very exciting area of development and is becoming widely accepted for use in many areas of neuropathic pain management. SCS does not eliminate pain but creates a numbness called paraesthesia in the area. This results in a masking of the pain.

SCS involves implanting electrodes into the epidural space near the source of pain. Different levels of the spinal cord innervate different areas of the body. For example, the nerves that supply the fingers exit the central nervous system at one level of the spinal cord, and the nerves that supply the toes exit at a different level. Therefore if the pain is experienced in the chest area, the electrodes will be placed at the level of the spinal cord where the nerves emerge to innervate the chest. The electrodes are connected to wires or leads threaded through the epidural space. The leads transmit the electric current that stimulates the pain inhibition pathways; this is powered by an external or internal source, known as the neuromodulator. The power is supplied in pulses that are adjusted to suit the individual's paraesthetic needs.

Devices used in SCS include:

Electrodes;Leads;Neuromodulator; andProgrammer. 
For a general overview on SCS, including more information on the mechanisms behind paraesthesia, and the indications, costs, advantages, risks and contraindications of SCS, see Spinal Cord Stimulation. 

SCS evokes paraesthesia by transmitting electric pulses through connecting leads to the electrodes. The electrodes are implanted in the epidural space at the level of the spinal cord, which innervates the area where the pain is experienced.

The number of electrodes used is determined by the level and complexity of the pain experienced. A more widespread, higher degree of pain requires more electrodes to be placed in the epidural space. More electrodes placed in the spinal cord provides more paraesthesia options, because not all electrodes are stimulated at all times.

The electrode stimulation pattern is controlled externally and each pattern will induce a slightly different sensation, some of which will provide more pain relief than others. If more electrodes are available, the number of pattern combinations that can be tested is increased. In order to expand these stimulation options further, a multi-array of electrodes is situated at the ends of the leads; usually this comprises of 4, 8 or 16 electrode contacts.

The leads are responsible for transmitting the electrical pulses generated by the neuromodulator to the electrodes, which are located at the end of the leads. The leads are thin wires inserted via a needle into the epidural space.

Paddle leads

The surgically implantable leads have a paddle-shaped electrode multi-array attached to the end, making them comparatively large compared to others available. Paddles provide an extensive coverage of the area and are used for more severe pain.

Percutaneous leads

Percutaneous leads have a slimmer design than paddle leads, which allows them to be easily manipulated and controlled. These leads are best for pain that is unusually dispersed and therefore requires more unusual overlap of paraesthesia benefits. Percutaneous leads are cheaper, faster and easier to insert and remove. For these reasons, these leads are commonly used for the trial period between electrode placement and generator implantation, although they carry a greater risk of infection and lead migration.

Percutaneous leads consume more battery power than paddle leads, and therefore require more frequent battery replacements or recharging.

The neuromodulator is the power source of the stimulator system. It can be either internally implanted, acting as a generator; or remain external, with transmission occurring via a radiofrequency system coupled to an internally implanted receiver. The neuromodulator produces the electric currents that are then transmitted to the spinal cord. All systems can control up to 16 electrodes per lead, giving rise to many stimulating patterns.

The choice of neuromodulator is entirely dependent on the individual's requirements and preferences. The predominant concerns dictating the choice are:

The need for controllability of the system; and The need for substantial power deliverability to stimulate adequate stimulation.

Convenience, financial and cosmetic factors for the individual are also taken into account.

Radiofrequency systems

The radiofrequency system operates by sending radio waves in pulses to the implanted receiver. As radiofrequency systems are not dependent on internal battery activation and require more power than other systems, they work best for people with high stimulation requirements and the most complex and intense pain. This is because when the stimulatory needs are greater, the battery will need to be replaced more frequently. Radiofrequency systems are powered by an external transmitter, which carries the battery, and is therefore easily replaced without invasive surgery.

The radiofrequency system is not as aesthetically pleasing as a fully implanted device, as an antenna and transmitter must be worn externally. In addition, the antenna can cause irritation.

Implantable pulse generator 

Implantable pulse generators (IPGs) are powered by an internal battery and must be replaced once it runs out. Recent developments have improved the size and battery life of IPGs.

Primary cell IPGs are similar to conventional implantable neuromodulators. They are suited to people who cannot operate a rechargeable system or do not require one. The batteries are high powered and have a life of up to 10 years, depending on use. The IPG can be implanted 2.5 cm under the skin. When the battery does need to be removed, it is a very minor procedure.

Rechargeable implantable pulse generator

The smallest neuromodulator currently available (10 mm wide and weighing less than 30 g) is a completely rechargeable implantable pulse generator, allowing the device to be used for a longer period. This means less invasive operations and a greater cost benefit. With a greater battery life, there is no need for major concern about conserving power on a day to day basis, and people implanted with this system should feel as though they can use the device as much as required. The remaining battery life is monitored by a controller. When the controller displays indicates low battery, the system needs to be recharged.

The device is completely implanted under the skin at a depth of about 2.5 cm. The battery is recharged via an externally controlled radiofrequency system. How often the battery must be recharged depends on use. Eventually, a point will be reached when the battery life per recharge will not last long enough for routine activities. It will then need to be surgically replaced.

Rechargable IPGs provide an alternative option for people with energy needs too high for the primary cell IPG, and whose only option in the past was radiofrequency systems. Substantial power requirements are still best served by radiofrequency.

The programmer provides a non-invasive way of adjusting the stimulator settings, or turning off the system completely. For some people, the effects of the stimulation can last for up to a week after the power is shut down.

When the system is turned on, the programmer allows electrode activation and pulse parameters to be selected. The pulse parameters are the timing between pulses, and the length of each pulse delivered to the electrodes. There will be a range of pulse parameters that can induce an adequate level of pain relief for each person.

The initial pulse parameter limits are set up by the doctor. Subsequently, the pulse parameters can be controlled and adjusted on a day to day basis by the person implanted with the system. The limits are put in place for safety, so the parameters cannot accidently be set too high or too low when not supervised by the doctor.

In the past, the settings on programmers were adjusted manually by the doctor, allowing only a small number of possible combinations to be trialled due to the relatively slow process of manual adjustment and limited time spent with the doctor. This has changed recently with increased research and development into the area. Programming is becoming more consumer interactive with the use of automated controls. This automated system allows the safe exploration of a larger array of contact combinations without supervision from the doctor.

The devices involved in SCS are continuously being improved, and as devices and implantation procedures become more technologically advanced, the treatment becomes even more cost effective and quality of life for those who receive SCS improves. Current research in the area is focused on further improving the effect of stimulation and expanding its compatibility to allow a broader range of people to be eligible for the treatment. Future aims include:

Increasing the number of contacts for each lead in order to better provide paraesthesia in the area;Designing the devices so they are compatible with MRI;Improving wireless options for control of the devices, for example through Bluetooth; and Improving lead delivery procedures in order to better target the spinal cord.
For more information about SCS, the conditions treated with SCS, SCS devices, and some useful videos and news, see Spinal Cord Stimulation.

International Neuromodulation Society
St Jude Medical website

Chronic pain management and pain relief

 

The Power Over Your Pain website provides information about neurostimulation and helps you connect with others who are experiencing the benefits of the treatment.

http://www.poweroveryourpain.com/

North R, Shipley J, Prager J, et al. Practice parameters for the use of spinal cord stimulation in the treatment of chronic neuropathic pain. Pain Med. 2007;8(Suppl 4):S200-75. [Abstract]Spinal cord stimulation [online]. Plano, Texas: St Jude Medical; 2009 [cited 25 August 2009]. Available from: URL link Bala MM, Riemsma RP, Nixon J, Kleijnen J. Systematic review of the (cost-)effectiveness of spinal cord stimulation for people with failed back surgery syndrome. Clin J Pain. 2008;24(9):741-56. [Abstract]North RB, Calkins SK, Campbell DS, et al. Automated, patient-interactive, spinal cord stimulator adjustment: A randomized controlled trial. Neurosurgery. 2003;52(3):572-80. [Abstract]Tripole paddle leads [online]. Plano, Texas: St Jude Medical; 2009 [cited 25 August 2009]. Available from: URL link Kreis PG, Fishman SM, Chau K. Impact to spinal cord stimulator lead integrity with direct suture loop ties. Pain Med. 2009;10(3):495-500. [Abstract]North NB, Wetzel FT. Spinal cord stimulation for chronic pain of spinal origin: A valuable long-term solution. Spine. 2002;27(22):2584-91. [Abstract]Percutaneous leads [online]. Plano, Texas: St Jude Medical; 2009 [cited 25 August 2009]. Available from: URL link EonC primary cell IPG system [online].Plano, Texas: St Jude Medical; 2009 [cited 25 August 2009]. Available from: URL link Genesis primary cell IPG system [online]. Plano, Texas: St Jude Medical; 2009 [cited 25 August 2009]. Available from: URL link Eon rechargable IPG system [online]. Plano, Texas: St Jude Medical; 2009 [cited 25 August 2009]. Available from: URL link Eon Mini rechargable IPG system [online]. Plano, Texas: St Jude Medical; 2009 [cited 25 August 2009]. Available from: URL link NeuroDynamix [online]. Plano, Texas: St Jude Medical; 2009 [cited 25 August 2009]. Available from: URL link Rapid programmer (R) 3.0 [online]. Plano, Texas: St Jude Medical; 2009 [cited 25 August 2009]. Available from: URL link Mekhail NA, Cheng J, Narouze S, et al. Clinical applications of neurostimulation: Forty years later. Pain Pract. 2010;10(2):103-12. [Abstract]

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