Archives of Integrative Clinical Practice
Volume 4, Issue 2, February 19, 2016
Previously Published – Free Content
ER Doctors Commonly Miss More Strokes Among Women, Minorities and Younger Patients
Physical Therapists are the safest providers of manipulation!
Effect of 10-week core stabilization exercise training and detraining on pain-related outcomes in patients with clinical lumbar instability
Clinical characteristics of pain originating from intra-articular structures of the knee joint in patients with medial knee osteoarthritis
5 Clues You Are Addicted To Sugar
Sensory and motor deficits exist on the non-injured side of patients with unilateral tendon pain and disability—implications for central nervous system involvement
A Systematic Review of Head-to-Head Comparison Studies of the Roland-Morris and Oswestry Measures’ Abilities to Assess Change
Three-dimensional computerized mobilization of the cervical spine for the treatment of chronic neck pain: a pilot study.
Vitamin D Supplementation: Who, and How Much? – Video
Nausea and Vomiting: What CAM Options Are Viable?
Recent Articles – Subscriber Content
Periodontal Disease and Risk of All Cancers Among Male Never-Smokers
Cartilage Degeneration, Osteoarthritis Symptoms, and Weight Loss in Obese and Overweight Individuals
Jim McMahon Concussion Treament – Video
Omega-3 Fatty Acids Prove Effective In Relieving Pain Caused By Diabetic Neuropathy
Knee Buckling Linked With Falls in Osteoarthritis
Breakfast Matters Little to Obese Adults
5 Ways Athletes Benefit from Chiropractic Care
Acupuncture Research Explained – Video
Non-steroidal anti-inflammatory drugs for chronic low back pain
Dietary nitrate lowers blood pressure
Consumption of fish oil providing amounts of EPA and DHA that can be obtained from the diet reduces blood pressure in adults with systolic hypertension: a retrospective analysis
The Peridural Membrane of the Human Spine is Well Innervated
Surgical versus non-surgical treatment for lumbar spinal stenosis
Exercise Reduces Risk for Low Back Pain
Medical Boards Fail to Punish Docs Who Commit Sexual Misconduct
Metabolically healthy obesity and development of chronic kidney disease: a cohort study
The inadequacy of musculoskeletal knowledge in graduating medical students in the United Kingdom
Exercise and meditation together help beat depression
Lifetime Marijuana Use and Cognitive Function in Middle Age
Plant extract shows promise in treating pancreatic cancer
High-cholesterol diet, eating eggs do not increase risk of heart attack, not even in persons genetically predisposed, study finds
Beet Juice Aids BP, Aerobic Endurance With Heart Failure
Mom’s Exposure to Car Smog May Up Child’s Asthma Risk
PPIs May Hike Dementia Risk in Elderly
The neuromechanical adaptations to Achilles tendinosis
Colonoscopy Complications Occur at Surprisingly High Rate
Training for improved neuro-muscular control of balance in middle aged females
Morbidity and mortality of complex spine surgery – 2015 Outstanding Paper Winner: Surgical Science
Elevated levels of tumor necrosis factor-α and TNFR1 in recurrent herniated lumbar discs correlate with chronicity of postoperative sciatic pain
ER Doctors Commonly Miss More Strokes Among Women, Minorities and Younger Patients
Many with dizziness and headaches sent home with missed diagnoses
FAST FACTS:
- Doctors overlook or discount early signs of potentially disabling strokes in tens of thousands of American each year.
- A large number of missed strokes occur in visitors to ERs who complain of dizziness or headaches but are sent home.
- Women, minorities and people under the age of 45 significantly more likely to be misdiagnosed.
- Neurologist David E. Newman-Toker, M.D., Ph.D., and his team studied federal health care data.
- A report on the research is published online in the journal Diagnosis.
David E. Newman-Toker, M.D., Ph.D. Christopher Myers Photography
The findings from the medical records review, reported online April 3 in the journal Diagnosis, show that women, minorities and people under the age of 45 who have these symptoms of stroke were significantly more likely to be misdiagnosed in the week prior to sustaining a debilitating stroke. Younger people in the study were nearly seven times more likely to be given an incorrect diagnosis and sent home without treatment despite such symptoms.
“It’s clear that ER physicians need to be more discerning and vigilant in ruling out stroke, even in younger people,” says study leader David E. Newman-Toker, M.D., Ph.D., an associate professor of neurology at the Johns Hopkins University School of Medicine. “Although stroke is less common in this demographic, we need to be more attuned to the possibility, particularly when the presenting complaint is dizziness or headache.”
Newman-Toker says he believes his research, which used Healthcare Cost and Utilization Project data from nine states for the years 2008–2009, is the first large-scale study to quantify stroke misdiagnosis. His team linked inpatient discharge records and emergency department visit records from 187,188 patients and 1,016 hospitals. They found that up to 12.7 percent of people later admitted for stroke had been potentially misdiagnosed and erroneously sent home from an ER in the 30 days preceding stroke hospitalization. Those misdiagnosed disproportionately presented with dizziness or headaches and were told they had a benign condition, such as inner ear infection or migraine, or were given no diagnosis at all. About half of the unexpected returns for stroke occurred within seven days, and more than half of these occurred in the first 48 hours.
Women were 33 percent more likely to be misdiagnosed and minorities were 20 to 30 percent more likely to be misdiagnosed, suggesting gender and racial disparities may play a role.
Nationwide, the estimated number of missed strokes resulting in harm to patients, based on the new data, could be anywhere between 15,000 and 165,000 annually, though Newman-Toker believes the number is likely between 50,000 and 100,000 a year. He notes that more specific numbers are difficult to estimate because of shortcomings in the health data routinely reported by the states.
Newman-Toker says early diagnosis and quick treatment of strokes are critical to the long-term health of patients having a transient ischemic attack (TIA) — a so-called “ministroke” or “pre-stroke” — because these temporary, non-disabling conditions are often a harbinger of a catastrophic bleed or clot in the brain that can lead to death or permanent disability just days later without appropriate treatment. Americans suffer an estimated 800,000 strokes a year, and another 200,000 to 500,000 experience a TIA. Prompt and early treatment may lower the risk of a repeat stroke by as much as 80 percent, Newman-Toker says.
In an earlier study in 2013, Newman-Toker and his colleagues estimated that misdiagnoses may account for 80,000 to 160,000 preventable deaths or permanent disabilities in each year in the United States with missed neurologic conditions, such as stroke, possibly accounting for a large share of disabling cases.
He adds that the most common type of stroke is best confirmed using MRI, rather than a CT scan, which often doesn’t show brain changes early on and can be falsely reassuring. And he notes that physicians should be able to differentiate between dizziness caused by a stroke and one caused by an inner ear problem using a series of relatively simple bedside tests tracking eye movements. Taking a good history and asking patients about their experience with headaches can reliably rule out a bleeding stroke from brain aneurysm.
“Most of these misdiagnosed patients, especially the younger ones, are probably people for whom stroke wasn’t really given much consideration or diagnostic assessment,” he says. “And this can have dire consequences.”
Researchers from the Agency for Healthcare Research and Quality (AHRQ), Blue Cross and Blue Shield of Minnesota and Truven Health Analytics contributed to the study, which was funded by AHRQ.
Physical Therapists are the safest providers of manipulation!
April 11, 2013 By Tim Flynn PT PhD
Thanks to Dr. Rob Landel and the California Orthopaedic Manual Physical Therapy Special Interest Group for the following post.
In my last post, I made it clear that physical therapists are more than adequately prepared, through their education and clinical experiences, to perform thrust joint manipulation (TJM). In this post, I like to address the issue of safety, more specifically, the claim that allowing physical therapists to perform spinal manipulation will prove harmful to the public. The two issues are closely interrelated.
The safe application of any technique requires the use of clinical judgment, specifically, determining not only who is appropriate for the technique, but also for whom the technique is contraindicated. This must occur prior to the procedure being performed. Adequate clinical judgment is based on knowledge of anatomy, pathoanatomy, biomechanics, pathomechanics, pathology, and a differential diagnostic process. Even the most skillfully applied technique can be harmful if done in the wrong circumstances. Also, the decision of whether or not to perform a manipulation must be evidence-based, i.e. taken into account the best available evidence, the clinician’s experience, and the patient’s needs and goals.
As I noted in my last post, all of these aspects are basic components of any Doctor of Physical Therapy program. Furthermore, this knowledge and clinical judgment is tested extensively through written, oral, and practical examinations, as well as put into practice during as much as one year of supervised clinical experiences. Finally, in order to become licensed in the state of California, every physical therapist must pass their licensure exam, which includes testing their knowledge and clinical judgment on manipulation, as required by the Federation of State Boards of Physical Therapy….
Effect of 10-week core stabilization exercise training and detraining on pain-related outcomes in patients with clinical lumbar instability
Patient Prefer Adherence. 2013 Nov 19;7:1189-99. doi: 10.2147/PPA.S50436. eCollection 2013.
Puntumetakul R, Areeudomwong P, Emasithi A, Yamauchi J.
Abstract
BACKGROUND AND AIMS:
Clinical lumbar instability causes pain and socioeconomic suffering; however, an appropriate treatment for this condition is unknown. This article examines the effect of a 10 week core stabilization exercise (CSE) program and 3 month follow-up on pain-related outcomes in patients with clinical lumbar instability.
METHODS:
Forty-two participants with clinical lumbar instability of at least 3 months in duration were randomly allocated either to 10 weekly treatments with CSE or to a conventional group (CG) receiving trunk stretching exercises and hot pack. Pain-related outcomes including pain intensity during instability catch sign, functional disability, patient satisfaction, and health-related quality of life were measured at 10 weeks of intervention and 1 and 3 months after the last intervention session (follow-up); trunk muscle activation patterns measured by surface electromyography were measured at 10 weeks.
RESULTS:
CSE showed significantly greater reductions in all pain-related outcomes after 10 weeks and over the course of 3 month follow-up periods than those seen in the CG (P<0.01). Furthermore, CSE enhanced deep abdominal muscle activation better than in the CG (P<0.001), whereas the CG had deterioration of deep back muscle activation compared with the CSE group (P<0.01). For within-group comparison, CSE provided significant improvements in all pain-related outcomes over follow-up (P<0.01), whereas the CG demonstrated reduction in pain intensity during instability catch sign only at 10 weeks (P<0.01). In addition, CSE showed an improvement in deep abdominal muscle activation (P<0.01), whereas the CG revealed the deterioration of deep abdominal and back muscle activations (P<0.05).
CONCLUSION:
Ten week CSE provides greater training and retention effects on pain-related outcomes and induced activation of deep abdominal muscles in patients with clinical lumbar instability compared with conventional treatment.
Clinical characteristics of pain originating from intra-articular structures of the knee joint in patients with medial knee osteoarthritis
Springerplus. 2013 Nov 23;2:628. doi: 10.1186/2193-1801-2-628. eCollection 2013.
Ikeuchi M, Izumi M, Aso K, Sugimura N, Tani T.
Abstract
PURPOSE:
Although disease progression of osteoarthritis has been well documented, pain pathophysiology is largely unknown. This study was designed with two purposes: 1) to characterize patients with knee pain predominantly originating from intra-articular structures and 2) to describe the location and pattern of their pain.
MATERIALS AND METHODS:
103 patients with medial knee osteoarthritis underwent an intra-articular injection of local anesthetics (joint block). At least 70% pain relief was defined as positive for the joint block, while less than 50% as negative. Pain characteristics in patients positive for joint block were evaluated in detail using a knee pain map.
RESULTS:
Sixty three knees (61%) were positive and 33 knees (32%) were negative. Patients negative for the joint block were significantly higher age, suffered for longer time, and complained more diffuse pain. Although pain at anterior medial area during walk was the most common finding, pain characteristics differed among different knee areas.
CONCLUSION:
The characteristics of joint pain are widely variable even in patients with similar radiological features. Extra-articular sources are not negligible especially in older patients with a long history of diffuse pain. Differences in pain characteristics among knee areas should be taken into account when examining the pain source.
5 Clues You Are Addicted To Sugar
By Mark Hyman, M.D.
November 21, 2014
Most of us have felt the urge, the unstoppable craving driving us to seek out something sweet and devour it in a flash. That uncontrollable yen for cookies, cake or ice cream or that whole basket of bread calling to us to finish it off. Why do you overeat? Why does that cookie have such power over you, even though you know it will make you fat and sick? Is it an indication of your moral weakness, lack of will power, or is it a powerful hardwired brain response over which you have little control?
Debate has raged recently about whether junk food, the hyper-processed, hyper-palatable food that has become our SAD (standard American diet) is addictive in the same way that heroin or cocaine is addictive. A new study published in the American Journal of Clinical Nutrition suggests that, in fact, higher sugar, higher glycemic foods can be addictive.
Sensory and motor deficits exist on the non-injured side of patients with unilateral tendon pain and disability—implications for central nervous system involvement
Br J Sports Med doi:10.1136/bjsports-2013-092535
Review
Sensory and motor deficits exist on the non-injured side of patients with unilateral tendon pain and disability—implications for central nervous system involvement: a systematic review with meta-analysis
L J Heales
Abstract
Introduction Tendinopathy manifests as activity-related tendon pain with associated motor and sensory impairments. Tendon tissue changes in animals present in injured as well as contralateral non-injured tendon. This review investigated evidence for bilateral sensory and motor system involvement in unilateral tendinopathy in humans.
Methods A comprehensive search of electronic databases, and reference lists using keywords relating to bilateral outcomes in unilateral tendinopathy was undertaken. Study quality was rated with the Epidemiological Appraisal Instrument and meta-analyses carried out where appropriate. Analysis focused on comparison of measures in the non-symptomatic side of patients against pain-free controls.
Results The search revealed 5791 studies, of which 20 were included (117 detailed reviews, 25 met criteria). There were 17 studies of lateral epicondylalgia (LE) and one each for patellar, Achilles and rotator cuff tendinopathy. Studies of LE were available for meta-analysis revealing the following weighted pooled mean deficits: pressure pain thresholds (−144.3 kPa; 95% CI −169.2 to −119.2 p<0.001), heat pain thresholds (−1.2°C; 95% CI −2.1 to −0.2, p<0.001), cold pain thresholds (3.1°C; 95% CI 1.8 to 4.4, p<0.001) and reaction time (37.8 ms; 95% CI 24.8 to 50.7, p<0.001).
Discussion Deficits in sensory and motor systems present bilaterally in unilateral tendinopathy. This implies potential central nervous system involvement. This indicates that rehabilitation should consider the contralateral side of patients. Research of unilateral tendinopathy needs to consider comparison against pain-free controls in addition to the contralateral side to gain a complete understanding of sensory and motor features.
A Systematic Review of Head-to-Head Comparison Studies of the Roland-Morris and Oswestry Measures’ Abilities to Assess Change
Physiother Can. 2013 Spring;65(2):160-6. doi: 10.3138/ptc.2012-12.
Newman AN, Stratford PW, Letts L, Spadoni G.
PURPOSE:
To determine if the sensitivity to change of Roland-Morris Questionnaire (RMQ) and Oswestry Disability Index (ODI) scores differ when applied to patients with low back pain (LBP). A secondary purpose was to critique the methodological rigour of the identified head-to-head comparison studies.
METHODS:
A systematic review of five online databases was performed to locate head-to-head comparison studies of the RMQ and the ODI that assessed the sensitivity to change of the two measures. Studies were eligible if they met a pre-determined set of inclusion criteria. A newly developed quality criteria form was used to evaluate the methodological rigour of head-to-head comparison studies.
RESULTS:
Nine articles met the inclusion criteria. Although there was a statistically significant difference in favour of the RMQ for two studies, there was no apparent consistent advantage of one measure over the other. Frequent methodological deficiencies included no formal sample size calculation, no formal between-measure comparison, and no independent reference standard.
CONCLUSION:
There was no consistent evidence supporting one measure over the other. Many studies displayed methodological deficiencies
Three-dimensional computerized mobilization of the cervical spine for the treatment of chronic neck pain: a pilot study
Pain Med. 2014 Jul;15(7):1091-9. doi: 10.1111/pme.12329. Epub 2014 Jan 8.
River Y
Abstract
BACKGROUND:
Manual therapies for chronic neck pain are imprecise, inconsistent, and brief due to therapist fatigue. A previous study showed that computerized mobilization of the cervical spine in the sagittal plane is a safe and potentially effective treatment of chronic neck pain.
OBJECTIVE:
To investigate the safety and efficacy of computerized mobilization of the cervical spine in a three-dimensional space for the treatment of chronic neck pain.
DESIGN:
Pilot, open trial.
SETTING:
Physical therapy outpatient department.
PARTICIPANTS:
Nine patients with chronic neck pain.
INTERVENTIONS:
A computerized cradle capable of three-dimensional neck mobilizations was used. Treatment sessions lasted 20 minutes, biweekly, for six weeks.
MAIN OUTCOME MEASURES:
Visual analog scale (VAS) for pain, cervical range of motion (CROM), neck disability index (NDI), joint position error (JPE), and muscle algometry.
RESULTS:
Comparing baseline at week one with week six (end of treatment), the VAS scores dropped by 2.9 points (P < 0.01). The six directions of movement studied by the CROM showed a combined increase of 11% (P = 0.01). The NDI decreased significantly from 16 to 10 (P = 0.03), and the JPE decreased significantly from 3.7° to 1.9° (P = 0.047). There was no change in the pressure pain threshold in any muscle tested. There were no significant adverse effects.
CONCLUSIONS:
These preliminary results demonstrate that this novel, computerized, three-dimensional cervical mobilization device is probably safe. The data also suggest that this method is effective in alleviating neck pain and associated headache, and in increasing the CROM, although the sample size was small in this open trial.
Wiley Periodicals, Inc.
Here is the The Occiflex device on YouTube:
Vitamin D Supplementation: Who, and How Much? – Video
Bret Stetka, MD; Robyn Lucas, PhD, BSc, MBChB, MPH&TM, MHE
Disclosures|January 13, 2014
Hello. I’m Bret Stetka, Editorial Director at Medscape. Welcome to the F1000 Practice-Changing Minute, during which we report commentaries from the Faculty of 1000 on highly rated studies that may change clinical practice. Today’s commentary covers the study “Effects of Vitamin D Supplements on Bone Mineral Density: A Systematic Review and Meta-analysis,” by Reid and colleagues and published in the Lancet.[1] Our commentator has given this study a ranking of “Changes Clinical Practice,” with the conclusion that vitamin D supplementation should not be prescribed to individuals without risk factors. Judicious testing of patients who have identifiable risk factors for vitamin D deficiency should be undertaken and treatment given as required if levels are < 40 nmol/L. The following F1000 commentary is from Dr. Robyn Lucas of the Australian National University, Canberra, Australia. In her commentary on this study, Dr. Lucas wrote: Prescribing vitamin D supplementation for osteoporosis to prevent fracture is common practice in many countries. Despite a few meta-analyses showing that vitamin D supplementation alone does not prevent hip fracture, several clinical trials and meta-analyses do show a decrease in risk of fractures and falls; however, the latter are mainly seen when supplementation is with vitamin D supplementation plus calcium. The current study examines vitamin D supplementation in relation to bone mineral density. The study authors found little evidence of a convincing positive effect of vitamin D supplementation in improving bone mineral density. They conclude that their analysis gives no support for the target of > 75 nmol/L concentration of 25-hydroxyvitamin D…which aligns well with the 2010 report of the Institute of Medicine, which determined that 40 nmol/L was an adequate concentration.
This study thus provides further support that there are health risks associated with vitamin D deficiency, but there is little evidence that levels higher than 40-50 nmol/L provide additional benefit.
Vitamin D supplementation should be reserved for those with risk factors for deficiency or proven deficiency on testing with an accurate and precise assay.
This concludes today’s commentary from Dr. Lucas. For the F1000 Practice-Changing Minute, I am Bret Stetka. Thank you for listening.
References
Reid IR, Bolland MJ, Grey A. Effects of vitamin D supplements on bone mineral density: a systematic review and meta-analysis. Lancet. 2013 Oct 10. [Epub ahead of print]
Nausea and Vomiting: What CAM Options Are Viable?
Désirée A. Lie, MD, MSEd
January 14, 2014
What Would You Do?
Case 1: Morning Sickness
Vicky is a 25-year-old primiparous woman in her 11th week of a normal pregnancy. She is experiencing excessive nausea and vomiting that is unrelieved by taking small frequent meals and eating crackers upon waking. Ultrasonography confirms a singleton pregnancy, and her hemoglobin level, metabolic panel, and urine tests are normal. She would like to avoid medications and asks whether she should try acupuncture, acupressure, or ginger for her symptoms.
Case 2: Motion Sickness
Mike is a 40-year-old man with a history of severe motion sickness induced by long car rides and boat trips. He is preparing to take a 2-week cruise. He would like a nonsedating alternative to antihistamines and anticholinergics to control motion sickness during his vacation. What might you suggest?
Nausea and Vomiting of Pregnancy: Does Anything Help?
Nausea and vomiting are common symptoms during the first trimester of pregnancy, occurring in almost one half of all women, and often persist until the fourth or fifth month (weeks 10-16) of pregnancy. Although typically self-resolving, these symptoms can lead to dehydration requiring hospitalization in a small minority of women. Hyperemesis gravidarum, a condition characterized by persistent vomiting, weight loss, ketonuria, electrolyte abnormalities, and dehydration, can affect as many as 2 in 100 pregnant women.
Acupuncture and acupressure. Several reviews have examined the use of acupuncture or acupressure for symptom control.[1-3] Acupuncture uses acupoint 6 (P6) proximal to the distal wrist crease for control of nausea, whereas acupressure can be applied manually or with wrist bands. Although studies have found acupressure to be more effective than sham acupressure,[2] larger studies have not demonstrated efficacy of either acupressure or acupuncture over sham acupuncture or no treatment.[2,3]
Ginger. Ginger (the rhizome Zingiber officinale) is a food condiment widely used in Asian cooking and as a traditional remedy for many conditions, such as dyspepsia, nausea and vomiting, constipation, bloating, and gingivitis, and for nongastroenterologic conditions such as fever and hypertension.[4-6]
Both animal and human studies have supported the antiemetic properties of ginger. Ginger extract,[7] ginger syrup,[8] and ginger capsules[9,10] have been reported in clinical trials to be superior to placebo for control of nausea and vomiting in pregnancy. A comparison[11]of ginger capsules (1 g daily in 4 divided doses) with vitamin B6 (pyridoxine) in early pregnancy found ginger to be more effective in reducing the severity of nausea but not in reducing the number of episodes of vomiting for women in early pregnancy, confirming findings from an earlier, smaller study.[12]
An evidence-based review in 2011[13] summarized the available evidence on the use of ginger. It concluded, on the basis of small heterogenous trials comparing ginger with placebo and other comparators, that the effectiveness of ginger was similar to that of dimenhydrinate and pyridoxine, and ginger was probably as safe as placebo. Its safety has been shown in some trials,[8] but other researchers have expressed concern about the potential risk for anticoagulant effects[14,15] and advise caution in terms of the dosage used during pregnancy, suggesting that further studies are needed. Ginger should certainly be avoided by persons on anticoagulation therapy, those with duodenal ulcers, or those at risk for intestinal obstruction.[1]
The American College of Obstetricians and Gynecologists (ACOG)[16] and the National Institute for Health and Clinical Excellence[17] both include ginger on their lists of acceptable therapies for the treatment of nausea and vomiting during pregnancy.
Hypnosis. Hypnosis has been recommended for nausea and vomiting during pregnancy as well as for symptoms associated with chemotherapy. However, a systematic review[18] identified only 6 clinical studies on hypnosis, with the evidence for efficacy being weak. Better-designed studies should be conducted in the future to assess the efficacy of hypnosis for hyperemesis gravidarum.[18]
A case report[19] from 2011 provides some insight into the use of brief hypnosis for persistent nausea and vomiting throughout pregnancy. More data are needed before hypnosis can be recommended to patients.
Motion Sickness
Motion sickness is a normal response to real, perceived,[20] or anticipated movement and can be triggered by the movement of a car, train, or airplane. It is experienced as seasickness by those on boats and is a concern of many persons who are contemplating a cruise.
The symptoms of motion sickness tend to be limited to the duration of the motion experienced. The symptoms, which include nausea and vomiting, dizziness, vertigo, cold sweat, disorientation, and fatigue, can be debilitating and particularly interfere with functioning at work for those whose jobs entail motion. Motion sickness can be visually induced (when there is no real motion) in virtual environments, such as simulators, cinemas, and video games. It is postulated that symptoms occur as a result of a mismatch among the visual, vestibular, and propioceptive systems.
Pharmacologic approaches. Pharmacologic measures for vestibular or visually induced motion sickness include transdermal scopolamine, an anticholinergic agent worn as a patch behind the ear that is applied up to 8 hours before travel; its effects last up to 3 days. Oral promethazine can be taken 2 hours before travel, with effects lasting 6-8 hours. Over-the-counter treatments include antihistamines, such as dimenhydrinate, meclizine, and cyclizine, but these can be sedating, impair cognition, and interfere with daily function. The type of medication taken should be customized to the duration and purpose of travel.
Nonpharmacologic approaches. Nutritional tips to reduce motion sickness include avoiding fatty or spicy meals; staying well hydrated; drinking ginger ale; and eating small, frequent meals. Among alternative therapies, acupressure,[21] wristbands,[22] and ginger[6,23,24] have been proposed as safe treatments. Other potential remedies include biofeedback training and relaxation,[25] deep breathing techniques, and cognitive-behavioral therapy,[26-29] modalities that have been tested on airplane pilots and were found to be helpful.
More recently, the use of relaxing and pleasant music has been proposed as a noninvasive and inexpensive countermeasure to visually induced motion sickness.[30,31] During a visually induced motion sickness experience, persons who listened to music that they self-reported as pleasant showed a significant reduction in motion sickness symptoms, with concomitant improved mood and emotion, compared with those who did not listen to pleasant music. The researchers postulated that the effect could be mediated by physiologic autonomic changes that promote relaxation and suggested more studies to examine the mechanism of this effect.
Case Resolution
After exclusion of more serious conditions, such as hyperemesis, multiple gestation, or diabetes, Vicky appears to have typical nausea and vomiting of early pregnancy. ACOG states that “treatment of nausea and vomiting of pregnancy with ginger has shown beneficial effects and can be considered as a nonpharmacologic option.”[16] Clinical trials have not confirmed the efficacy of acupuncture or acupressure for symptom control.
If Vicky does not have a bleeding diathesis and is not on anticoagulant medication, a trial of ginger capsules at 250 mg 4 times daily is warranted. She can also be reassured that these symptoms should subside as pregnancy progresses.
Mike has troublesome motion sickness that may prevent his enjoyment of his vacation, and he is eager to avoid anticholinergics and antihistamines. There are several nonsedating complementary and alternative medicine options with minimal side effects that he can try. The use of pleasant music, which he can enjoy on any digital device, could act as a countermeasure before and during travel. Wristbands that provide acupressure at the P6 point can be worn during the cruise. In addition, ginger capsules at a dose of 250 mg given 3 times daily may alleviate the symptoms of seasickness.