Category: jklhvrtn

first_img20th May 2020 | By Joanne Christie AddThis Sharing ButtonsShare to LinkedInLinkedInShare to FacebookFacebookShare to TwitterTwitter Tags: Online Gambling iGB Market Monitor – May 2020 Sports betting Subscribe to the iGaming newsletter It would be easy to put the industry’s current problems down to the unexpected novel coronavirus (Covid-19) virus that spread rapidly throughout the world.But the pandemic has done more than just put the brakes on the sports betting vertical and have a huge revenue impact on the wider igaming market. It has highlighted and exacerbated issues that were already at the fore in the gambling market.The debate over gambling advertising was already front and centre in many jurisdictions and has become even more so since lockdowns were put in place.Gambling critics have used the spectre of bored housebound consumers piling into online gambling to drive home their demand for advertising bans and regulatory reform and in some ways, they’ve been successful.Regulators in a number of European countries have taken action to curtail gambling during the lockdown period and there is talk of further clampdowns in the UK and Sweden, the countries that are the focus of this Market Monitor.In the UK, the virus came at a time when the market was already contracting and when voices from groups such as the Gambling Related Harm All Party Parliamentary Group were growing increasingly louder.The efforts of the Betting and Gaming Council in co-ordinating a voluntary ad ban during the crisis have done little to appease the industry’s detractors, who now want the ban to be made permanent.In Sweden, proposals by authorities to further limit deposits and ban betting on lower league football could potentially lead to channelisation falling even further in the relatively newly regulated market.A recent report from Copenhagen Economics provides some compelling and worrying evidence to suggest that rather than driving out the grey market operators, the regulator’s actions so far might be having the opposite effect.All of this points to the idea that the regulatory and legislative responses to gambling during the coronavirus crisis will be just as important as the lifting of lockdowns and reopening of sporting events in determining how the industry comes out of this crisis.Stephen CarterEditorial director, iGBYou can also download the PDF from here This edition of the iGB Market Monitor drills down into the latest public numbers and data from the United Kingdom and Sweden Regions: Europe UK & Ireland Nordics Sweden Topics: Casino & games Finance Legal & compliance Sports betting Bingo Email Addresslast_img read more

first_imgTotal Kenya Limited ( listed on the Nairobi Securities Exchange under the Energy sector has released it’s 2010 interim results for the first quarter.For more information about Total Kenya Limited ( reports, abridged reports, interim earnings results and earnings presentations, visit the Total Kenya Limited ( company page on AfricanFinancials.Document: Total Kenya Limited (  2010 interim results for the first quarter.Company ProfileTotal Kenya Limited is the largest oil and gas marketer in Kenya with an extensive network of service stations and fuel depots, liquefied petroleum gas filling plants and aviation depots. The Kenyan oil and gas company is a subsidiary of the global Total Group which is the fourth-largest publicly traded integrated international oil and gas company in the world with a presence in over 100 countries. The company was founded in 1955 as OZO East Africa Limited but changed its name to Total Oil Products East Africa Limited in 1988, making it the first multi-national oil company listed on the Nairobi Securities Exchange. The company changed its name to Total Kenya Limited in 1991. Total Kenya Limited has more than 176 service stations, 5 wholly-owned fuel depots and 3 jointly-owned depots, 2 liquefied petroleum gas filling plants, 1 lubricant blending plant and 5 aviation depots. Its head office is in Nairobi, Kenya. Total Kenya Limited is listed on the Nairobi Securities Exchangelast_img read more

first_imgGeneral Beltings Holdings Limited ( listed on the Zimbabwe Stock Exchange under the Industrial holding sector has released it’s 2018 interim results for the half year.For more information about General Beltings Holdings Limited ( reports, abridged reports, interim earnings results and earnings presentations, visit the General Beltings Holdings Limited ( company page on AfricanFinancials.Document: General Beltings Holdings Limited (  2018 interim results for the half year.Company ProfileGeneral Beltings Holdings Limited (GBH) manufactures and distributes general-purpose and specialised reinforced conveyor beltings, and rubber and chemical products. Its product range includes rubber-covered belting, polyvinyl chloride (PVC) belting, light-duty PVC belting, solid-woven belting, transmission belting and conveyor belt rubber skirting. Its two major customers are Anglo-American Corporation and De Beers. The company has two subsidiaries; Pigott Maskew and General Beltings. Pigott Maskew manufactures rubber products for mining, manufacturing and construction industries; with a product range covering large and small bore reinforced rubber hoses, rubber agricultural and construction rings, rubber sheeting, rubber gasket material, molded rubber products, rubber extrusions and rubberized charge car wheels. General Beltings Limited is listed on the Zimbabwe Stock Exchangelast_img read more

first_img Ben Watson | Wednesday, 4th November, 2020 | More on: CNA See all posts by Ben Watson I would like to receive emails from you about product information and offers from The Fool and its business partners. Each of these emails will provide a link to unsubscribe from future emails. More information about how The Fool collects, stores, and handles personal data is available in its Privacy Statement. Image source: Getty Images Simply click below to discover how you can take advantage of this. I’m sure you’ll agree that’s quite the statement from Motley Fool Co-Founder Tom Gardner.But since our US analyst team first recommended shares in this unique tech stock back in 2016, the value has soared.What’s more, we firmly believe there’s still plenty of upside in its future. In fact, even throughout the current coronavirus crisis, its performance has been beating Wall St expectations.And right now, we’re giving you a chance to discover exactly what has got our analysts all fired up about this niche industry phenomenon, in our FREE special report, A Top US Share From The Motley Fool. Click here to claim your copy now — and we’ll tell you the name of this Top US Share… free of charge! bwatson1 owns shares of Centrica. The Motley Fool UK has no position in any of the shares mentioned. Views expressed on the companies mentioned in this article are those of the writer and therefore may differ from the official recommendations we make in our subscription services such as Share Advisor, Hidden Winners and Pro. Here at The Motley Fool we believe that considering a diverse range of insights makes us better investors.center_img The Scottish author Samuel Smiles wrote “we learn wisdom from failure much more than from success”. For me, this neatly sums up my investment in Centrica (LSE: CNA). Purchased as a defensive utility stock in 2010 at 326p, I briefly watched in satisfaction as my holding ticked up in value. I supported the share price growth with dividend reinvestment. In 2013, the Centrica share price touched an all-time high of over 400p.Centrica share price – the downturnSince that fateful day, Centrica has unleashed wave after wave of bad news onto shareholders. Numerous complaints about customer service and high prices forewarned an exodus of subscribers, at one point over 100k per month. Weak oil and gas prices accounted for more revenue falls. A struggle to dispose of unwanted assets led to another investor sell-off, and the Centrica share price continued to fall.5G is here – and shares of this ‘sleeping giant’ could be a great way for you to potentially profit!According to one leading industry firm, the 5G boom could create a global industry worth US$12.3 TRILLION out of thin air…And if you click here we’ll show you something that could be key to unlocking 5G’s full potential…For a short while I consoled myself with a generous dividend payment. This was cut in 2015, then suspended entirely amid the Covid-19 pandemic. Centrica was then demoted from the FTSE 100. All said and done, I sit on an 81% loss on Centrica share price capital as I write. This is before considering the opportunity cost of the investment. Had I put my money into Scottish Mortgage Investment Trust in 2010, I would now be rewarded with a staggering 771% growth.Foolish adviceI write this short confessional to Foolish readers to try and prevent you making the same mistakes as I did. Harvey Jones has told the story of the Centrica share price over the last decade. There were numerous opportuinities to sell my holding each time the bad news arrived, but I was reluctant to crystalise a loss. “Maybe they’ll recover”, I kept telling myself. The harsh lesson I learnt is that there can sometimes be no end to bad news. It is better to cut and run as early as possible.Centrica share price – the current pictureLower energy demand from businesses during the first half of 2020 saw revenues falling 14% and operating profits down 9%. An increase in residential demand has partially offset this. However, with homes and businesses suffering from Covid-19-related financial hardship, the group will have to increase provision for deferred payments and bad debts. Encouragingly, cash flow and liquidity remain strong. This puts the group in a good position to navigate the ongoing pandemic.There are signs that the group is entering a turnaround phase. It is easy to forget that Centrica is still the UK’s biggest household energy supplier, but hasn’t yet fully exploited this position. The simplification of the business coming from offloading exploration and nuclear divisions should bring stability. Restructuring should help increase profit margins over the next two years.Foolish summaryAs new chief executive, Chris O’Shea, gets to grips with a turnaround strategy there could be a case for a value investment. The Centrica share price may see significant upside potential. In my opinion, however, there are better candidates within the FTSE for this kind of investment strategy. As such, I will retain my current holding in the hope of growth and dividend reinstatement, but I certainly will not be adding to it. Renowned stock-picker Mark Rogers and his analyst team at The Motley Fool UK have named 6 shares that they believe UK investors should consider buying NOW.So if you’re looking for more stock ideas to try and best position your portfolio today, then it might be a good day for you. Because we’re offering a full 33% off your first year of membership to our flagship share-tipping service, backed by our ‘no quibbles’ 30-day subscription fee refund guarantee. Tempted by the Centrica share price? Read this first Enter Your Email Address Our 6 ‘Best Buys Now’ Shares “This Stock Could Be Like Buying Amazon in 1997”last_img read more

first_imgHow I’d start earning passive income with just £50 a week Click here to claim your copy now — and we’ll tell you the name of this Top US Share… free of charge! “This Stock Could Be Like Buying Amazon in 1997” I’m sure you’ll agree that’s quite the statement from Motley Fool Co-Founder Tom Gardner.But since our US analyst team first recommended shares in this unique tech stock back in 2016, the value has soared.What’s more, we firmly believe there’s still plenty of upside in its future. In fact, even throughout the current coronavirus crisis, its performance has been beating Wall St expectations.And right now, we’re giving you a chance to discover exactly what has got our analysts all fired up about this niche industry phenomenon, in our FREE special report, A Top US Share From The Motley Fool. Image source: Getty Images. Making a passive income could be simpler and more accessible than many people realise. After all, the process of setting up a tax-efficient account such as a Stocks and Shares ISA, buying dividend shares and holding them for the long run is relatively cheap and straightforward.Through investing regularly, it is possible to build a surprisingly large nest egg over the long run that provides a generous income return. It could improve an individual’s financial position over the coming years.5G is here – and shares of this ‘sleeping giant’ could be a great way for you to potentially profit!According to one leading industry firm, the 5G boom could create a global industry worth US$12.3 TRILLION out of thin air…And if you click here we’ll show you something that could be key to unlocking 5G’s full potential…Opening a Stocks and Shares ISAA Stocks and Shares ISA is a sound means through which to generate a passive income. It can be set up online in a matter of minutes. And it provides tax efficiency versus a bog-standard share-dealing account. Moreover, management fees for an ISA are no more than the cost of a single trade in many cases. Regular investment services are often available on ISA accounts too. That means investors with limited funds can benefit from the income opportunities provided by the stock market.A Stocks and Shares ISA also provides greater flexibility than other tax-efficient accounts such as a SIPP. Withdrawals from an ISA can be made at any time and without penalty. That is often not the case with other types of accounts. This may make them especially useful to those seeking a passive income, but wanting access to their capital in case of emergency.Investing in dividend shares for a passive incomeMaking a passive income is more difficult now than it has been in previous years due to low interest rates. But dividend shares continue to offer high yields in many cases. For example, the FTSE 100 contains a wide range of businesses with 5%+ dividend yields at present. Buying a diverse range of such stocks could be a sound means of making a worthwhile income. And it could limit the risk of loss should any holdings meet challenging operating conditions.Furthermore, buying dividend shares that have the capacity to raise their shareholder payouts could be a sound move. They may pay out a lower proportion of profit as a dividend than their peers, or could have sound profit forecasts that suggest a higher dividend may be ahead.Starting small to make a large nest eggClearly, investing £50 per week is unlikely to produce a large passive income in the short run. However, an investor who reinvests dividends could realistically obtain a large portfolio in the long run.For example, investing £50 per week at the same rate of return as the FTSE 100 has managed in recent decades of 8% would produce an ISA portfolio valued at over £200,000 within 25 years. From this, a 5% yield equates to an annual income of £10,000. This could provide a useful supplement to the State Pension in older age, and lead to greater financial freedom in retirement. Enter Your Email Address I would like to receive emails from you about product information and offers from The Fool and its business partners. Each of these emails will provide a link to unsubscribe from future emails. More information about how The Fool collects, stores, and handles personal data is available in its Privacy Statement. Peter Stephens | Wednesday, 6th January, 2021 Simply click below to discover how you can take advantage of this. Our 6 ‘Best Buys Now’ Shares Renowned stock-picker Mark Rogers and his analyst team at The Motley Fool UK have named 6 shares that they believe UK investors should consider buying NOW.So if you’re looking for more stock ideas to try and best position your portfolio today, then it might be a good day for you. Because we’re offering a full 33% off your first year of membership to our flagship share-tipping service, backed by our ‘no quibbles’ 30-day subscription fee refund guarantee. See all posts by Peter Stephenslast_img read more

first_imgHome Indiana Agriculture News California-Based Agbiosciences Company to Establish New Swine Farm in Jasper County SHARE By Hoosier Ag Today – Aug 30, 2018 Facebook Twitter SHARE Facebook Twitter California-Based Agbiosciences Company to Establish New Swine Farm in Jasper County Lt. Governor Suzanne Crouch and Jasper County officials joined executives from Premier BioSource, an agriculture biosciences company specializing in the production of research-purposed swine, broke ground on the company’s first Indiana farming operation in Rensselaer Thursday.“With our strong agricultural tradition and thriving life sciences sector, Indiana offers a winning solution for companies like Premier BioSource who provide high-quality swine to research institutions across the U.S.,” said Lt. Governor Crouch, who also serves as Indiana’s Secretary of Agriculture and Rural Development. “We are excited Premier BioSource chose to locate here in Indiana, and I am confident that our hardworking Hoosier workforce will help propel their future success.”The Ramona, California-based company will invest nearly $7.5 million to construct and equip a 78,000-square-foot, 600-sow, farrow-to-finish farm operation in Rensselaer. Premier BioSource’s pigs will be used solely for biomedical research and product development, contributing to advancements in heart stents, cardiac repair and rejuvenation, diabetes and insulin research, and surgical procedures. With plans to be operational by June 2019, the facility will house 4,752 pigs at full capacity and supply the company’s eastern U.S. client base.Premier BioSource, which has 11 employees across the U.S., plans to add up to 21 new jobs in Indiana and begin hiring in 2019 for positions in animal care and transportation services. Interested applicants may apply by contacting Jon Hoek, general manager of Premier BioSource.“Indiana was a perfect fit for Premier BioSource because of its friendly business environment and rich agricultural heritage,” said Mark Bousema, president of Premier BioSource. “Couple that with Rensselaer’s close proximity to our customers and access to quality labor, this was an easy choice for our company.”Founded by Tom and Carl Salayer in 1987, Premier BioSource raises top-quality swine, which share many physiological and anatomical similarities with humans, for the biomedical research community. Through its partnership with Indiana-based Summit Livestock Facilities, the company’s Jasper County farm operation will be designed to facilitate regulatory compliance, improve animal health and production, enhance operational efficiencies and address social concerns.“Jasper County is a leader in Indiana’s agriculture sector, consistently being a top producer in both crops and livestock,” said Jasper County Commissioner Kendell Culp, who also serves as vice president of the Indiana Farm Bureau. “Premier BioSource is a state-of-the-art company. We are pleased that they chose to locate in Jasper County; our strong work ethic and commitment to 21st century agriculture makes us an agribusiness hot spot.”The Indiana Economic Development Corporation (IEDC) offered S&S Farms, LP (dba Premier BioSource) up to $130,000 in conditional tax credits based on the company’s job creation plans. These incentives are performance-based, meaning until Hoosiers are hired, the company is not eligible to claim incentives. The Jasper County Commissioners and Jasper County Economic Development Organization are supportive of the project.Indiana’s agriculture and agribusiness industry supports more than 107,000 Hoosier jobs and contributes an estimated $31 billion to the state’s economy annually. In addition, the state has earned a reputation as a global leader in the life sciences industry, ranking second in the nation in worldwide exports according to BioCrossroads and the Indiana Business Research Center. With the state’s significant research and training capabilities at its colleges and universities, Indiana is well positioned to propel new advancements and breakthrough technologies at the intersection of both industries.Source: Indiana Economic Development Corporation Previous articleThe HAT Soil Health Podcast- Soil Health and Water QualityNext articleAdministration on E15: “Let’s Get it Done” Hoosier Ag Todaylast_img read more

first_imgLinkedin TCU places second in the National Student Advertising Competition, the highest in school history Mel Morris World Oceans Day shines spotlight on marine plastic pollution TCU 360 archives ReddIt Twitter Linkedin What we’re reading: Buttigieg drops out of the race and COVID-19 continues to spread in the US Welcome TCU Class of 2025 Previous articleWhat we’re reading: Pelosi announces impeachment inquiry against President TrumpNext articleHoroscope: September 24, 2019 Mel Morris RELATED ARTICLESMORE FROM AUTHOR printA Froggie Five-0 driver at the intersection on University Drive. Photo by TCU 360 staff. Froggie Five-0 will add two new carts to its line up next month after complaints from drivers about the carts’ condition, Assistant Vice Chancellor of Public Safety Adrian Andrews said.“The older carts had gotten to the point that they were always being repaired,” Andrews said. “We wanted to make sure that our young people have the best transportation that they need.”The new carts will look exactly the same but will ride smoother, Andrews said.The Froggie carts are in poor condition because drivers drive off curbs and crack the axles and do not take care of maintenance, Andrews said. All Froggie Five-0 drivers escort students in golf carts. Andrews said that new carts are purchased every four to five years due to this typical wear and tear.“Some of them break down so much that they’re in the shop more than they’re being used, so it’s about time,” said Kenny Houston, the head supervisor of Froggie Five-0. The current Froggie Five-0 drivers receive specific training about maintenance and safety rules at the beginning of each year, which is a new policy. This will eliminate unnecessary servicing of the vehicles and give the carts a longer shelf life.Two of the nine previous carts will be retired before the new ones are added, Andrews said. “We will probably have the new ones for about four to five years and we will try to maintain them and keep them in great shape before we turn those in,” Andrews said.Houston said he was delighted about the addition of new carts.“The riders will probably enjoy the new ones more because they will be quieter and probably not as bumpy as the old ones,” Houston said.Phil Olson, an accounting graduate student, complained that the current carts “are very loud and annoying.”Andrews said the older Froggie carts had a slower acceleration rate due to their long-time use. The addition of new carts will allow for faster response times and be more pleasant for all parties involved. Blythe Bonan, a senior communication major, said the carts were inefficient and bumpy. The cart she was on was so rough that she was bumped off.“I did fall off of a cart one time, and they are pretty slow,” Bonan said.Andrews also said that an influx in the number of students has led to more escort requests and the need for new carts. The new carts will be delivered within the next couple of months. Mel Morris Will you be my quarantine? Mel Morris TCU to host a mental health panel Facebook Facebook National Finals Rodeo heads to Globe Life Field this December Mel Morris + posts ReddIt Mel Morris Twitterlast_img read more

first_img Data Provider Black Knight to Acquire Top of Mind 2 days ago Previous: The Applicability of Contempt Sanctions in Bankruptcy Next: Addressing Race in Home Inventory and Rental Policies January 20, 2020 972 Views Servicers Navigate the Post-Pandemic World 2 days ago Home / Daily Dose / The Ties Between ‘Global Uncertainty’ and Housing Trends The Ties Between ‘Global Uncertainty’ and Housing Trends The Best Markets For Residential Property Investors 2 days ago  Print This Post Mike Albanese is a reporter for DS News and MReport. He is a University of Alabama graduate with a degree in journalism and a minor in communications. He has worked for publications—both print and online—covering numerous beats. A Connecticut native, Albanese currently resides in Lewisville. Governmental Measures Target Expanded Access to Affordable Housing 2 days ago The Best Markets For Residential Property Investors 2 days ago Share Save About Author: Mike Albanese housing market 2020 trade wars treasury yields 2020-01-20 Mike Albanesecenter_img Sign up for DS News Daily fcd1aa2d-5b26-4754-ab6b-8342360620f8Analysis from First American Financial Corporation says global uncertainty—such as the conflict between the U.S. and Iran—impacts not only geopolitical relations but also the U.S. housing market. “When global investors sense increased uncertainty, there is a ‘flight to safety’ in U.S. Treasury bonds, which causes their price to go up, and their yield to go down—U.S. homebuyers benefit from this dynamic,” said Mark Fleming, Chief Economist at First American. Fleming said the 30-year fixed-rate mortgage follows the 10-year Treasury bond. Since the end of the recession, the 30-year fixed-rate mortgage remained 1.7 percentage points higher than the 10-year Treasury yield. He added that if this trend continues, and the 10-year Treasury yield dips to 1.5% due to uncertainty and a global “flight to safety,” then the 30-year fixed-rate mortgage could fall as low as 3.2%. “The 30-year, fixed-rate mortgage fell to its lowest level in a month in response to the decline in the 10-year treasury yield on the morning after the U.S. airstrike in Iran,” Fleming said. First American reported that the second-largest shift in the 30-year fixed-rate mortgage since the end of the Great Recession occurred following the 2016 Presidential election. Mortgage rates increased to 3.94% from 3.57% the week after the election. A few months earlier, the U.S. Treasury bond yield declined by 0.29 percentage points and mortgage rates fell 0.29 percentage points in the weeks that followed the “Brexit” vote in June 2016. “More recently, the decline in mortgage rates since the beginning of 2019 has been partly due to uncertainty around the outcome of U.S.-China trade relations, including the largest single-week decline in the mortgage rate (0.22 percentage points) since the end of the Great Recession in March 2019,” Fleming said. First American’s Real House Price Index from October 2018 found that the 10-year Treasury yield was 1.7% and the 30-year fixed-rate mortgage was 3.7%. With an average national household income of nearly $66,400, consumer house-buying power, the combination of one’s income, and the prevailing mortgage rate was $418,000.Fleming said that even a small change in the 10-year Treasury yield—even a small drop of 1.6%—would bring a mortgage rate of 3.3%. “Assuming no change in household income, that would mean a house-buying power gain of $21,000, a five percent increase. Amid uncertainty, the house-buying power of U.S. consumers can benefit significantly,” he said. Related Articles in Daily Dose, Featured, Market Studies, News Tagged with: housing market 2020 trade wars treasury yields Demand Propels Home Prices Upward 2 days ago Data Provider Black Knight to Acquire Top of Mind 2 days ago The Week Ahead: Nearing the Forbearance Exit 2 days ago Servicers Navigate the Post-Pandemic World 2 days ago Governmental Measures Target Expanded Access to Affordable Housing 2 days ago Demand Propels Home Prices Upward 2 days ago Subscribelast_img read more

first_img WhatsApp Google+ Pinterest Important message for people attending LUH’s INR clinic Community Enhancement Programme open for applications News, Sport and Obituaries on Monday May 24th Twitter Arranmore progress and potential flagged as population grows Previous articleFairyhouse win for Conor OrrNext article49 Garda members self-isolating in Donegal due to Covid-19 News Highland Facebook Loganair’s new Derry – Liverpool air service takes off from CODA Google+center_img WhatsApp RELATED ARTICLESMORE FROM AUTHOR Homepage BannerNews Nine til Noon Show – Listen back to Monday’s Programme Twitter Burst pipe causes water outage in Inishowen Facebook Pinterest A number of homes and businesses are without water this afternoon in Inishowen due to a burst water main.Irish Water say repairs may cause supply disruptions to Mullaney and Bohillion in Burt and surrounding areas.Works have an estimated completion time of 8 o clock tonight.Irish Water have recommend that you allow 2-3 hours after the estimated restoration time for your supply to fully return.Local Councillor Paul Canning has asked those in the area that can preserve water, to do so. By News Highland – January 17, 2021 last_img read more

first_imgBack problems have a nasty tendency to become chronic and the outcome isheavily dependent on the attitude of the patient and the healthcareprofessional. Unhelpful beliefs must be challenged and individuals involved intheir own recovery programme, by Dr Grahame Brown Disability attributable to back pain in people of working age is one of themost spectacular failures of modern health care in the industrialised world.Its greatest impact is on the lives and families of those affected. However, italso has a major effect on industry through absenteeism and avoidable costs, onsocial security costs and on pension schemes. This article looks at ways inwhich health care professionals can reduce the risk of adding to this massivepersonal, social and economic burden when individuals present with thecomplaint of back pain. All healthcare professionals involved in managing people with back pain mustbe familiar with a paradigm shift in thinking about this problem with thepublication of Waddell’s The Back Pain Revolution.1 However, attitudes, beliefsand behaviour must change in healthcare professionals as well as patients, andfrequently it is the former who are more resistant to change. A recent evidence review from the Faculty of Occupational Medicine, London2highlights our current state of knowledge and makes recommendations that areessential reading for any OH professional. It is clear that attempts over the past few decades (supported bylegislation) to prevent back pain occurring in the workplace (primaryprevention) have been unsuccessful. These methods have been largely based onthe injury model of back pain (for example, manual-handling training) andconcentrate on the orthodox, disease model of medicine. The only evidence todate that activity in the workplace aimed at primary prevention has had anyeffect on outcomes that matter to individuals and employers is the promulgationof information that challenges attitudes and beliefs based on acognitive-behavioural model.3-5 At present, these methods, and secondary andtertiary prevention strategies, provide the most effective means of reducingthe risk of costly chronicity and disability. Treatment aims The goals are to prevent disability and chronicity developing. OccupationalHealth professionals are in an ideal position to see workers who are havingdifficulty with back pain early in the course of events and to influencepositively the outcome. The first consultation a person troubled by back pain has with a health careprofessional is probably the most important. It will either set that person onthe road to recovery and restoration of function or, as happens all too often,it will precipitate despair, depression and disability. So, at this importantstage, it is helpful for the health care professional to have in mind a fewimportant facts and questions: – The complaint of back pain affects everyone at some time, with 90 per centof us experiencing significant interference with daily activities for at least48 hours at some time in our lives. And 40 per cent will experience recurringproblems with our backs – Psychosocial factors may operate at different stages in the developmentand perpetuation of low back pain. These factors may have precipitated thefirst consultation for the complaint. Often, unfortunately, causation iswrongly attributed to what the person was physically doing when firstcomplaining of symptoms. It is important to know the risk factors forchronicity and disability – Make an initial assessment of the clinical problem: Is it ‘simple back pain’,nerve root pain or is there possible serious pathology? If there are anysymptoms that give cause for alarm, for example, age of onset less than 20 orgreater than 55 years, or the presence of constant progressive pain, thepatient should be referred promptly to a surgeon. Referring a patient willensure laboratory tests, including full blood count, sedimentation rate andbiochemistry screen are performed to rule out occult pathology – Ask yourself the question: “What can I do right now to reduce the riskof this person becoming disabled or a chronic sufferer?” Most often thiswill not involve skilled physical treatments but will be achieved by reducinganxiety and emotional arousal, challenging unhelpful attitudes and beliefs,providing positive information and involving individuals in their own recoveryprogramme. Giving the person a copy of The Back Book4 to read is likely to bevery effective The interview with the patient is vitally important. Remember threefunctions of the medical interview: – Establish rapport: Greet the patient warmly and by name. Listen activelyand reflectively. Detect and respond to emotional cues – Collect data: Do not interrupt the patient. Use open questions first andcollect accurate information with closed questions later. Elicit patient’sexplanatory model. Develop a shared understanding – Negotiate and agree a management plan. Provide information. Usereassurance appropriately. Make links. Negotiate behaviour change An interview conducted in this way can be very therapeutic in itself. Thisperson-centred (as compared with a purely disease-based) approach improvesoutcomes that matter to patients, shortens follow up and reduces unnecessaryinvestigations. Physical treatments OH departments do not normally provide physical treatment services, but someuse in-house physiotherapists, or osteopaths. It is important to target thisservice where it is most likely to be effective for the patient andeconomically viable for the organisation. For example, after 12 weeks’ sickness absence, figures show that 25 per centof workers with low back pain will never return and this figure increases to 50per cent by 26 weeks off. When the goal is to reduce long-term sickness absence, it therefore appearsthat the group of workers to whom available resources are best targeted arethose who are off work for between four and 12 weeks. Interventions provided tothose who are at work but struggling are arguably no less important to helpthem remain functioning. Those at work and coping with nuisance symptoms notinterfering with their ability to work are a low priority. Some form ofpriority has to be given when resources are insufficient to meet demand. Whatever the course of treatment for low back pain, or any other regionalpain problem, it is worth remembering that if it is not beginning to make anyuseful difference to the patient, as shown by improved function, by, at themost, six treatments, it is not working. Reassess, review the obstacles torecovery and do something different. Prolonging ineffective treatments is verydamaging to the psychological well-being of the patient. Much can be done and begins at the first consultation. Some important pointsare: – Encourage a return to work as soon as possible; there is no need to waituntil all the pain has gone – Make a return to normal work the goal: this reinforces the belief in thepatient that normality can be achieved. It also, and vitally, reducesfear-avoidance beliefs and behaviour – Use a fixed period for return to work, with a gradual increase in activityand responsibility to help achieve a return to normal activities. This must betime-limited, with goals set and reviews arranged. Some form of temporaryrestrictions may be helpful, but must be time-limited. It is a mistake to allowrestrictions to depend on ‘how the patient feels’: this encourages pain andillness behaviour and only creates more problems in the future, which are evenmore difficult to solve – Use treatments that facilitate active rehabilitation and that do notinterfere with it – Consider short spells in functional restoration programmes for those whohave demonstrated a commitment to work hard to improve their functionalcapacity, but are having difficulty. These excellent (but expensive) programmesshould not be used, however, in the hope that they can magically motivate aperson who has learned helplessness, is depressed, is focused on compensationissues of whatever nature or who has no belief that their quality of life oroccupational status can be improved – Support and encourage the person through the difficulties and setbacksthat will inevitably occur. OH professionals are in an ideal position to dothis – Consider redeployment or severance only when all reasonable attempts havebeen made to rehabilitate to normal work. Healthcare professionals not trainedin OH frequently advise patients, who mention during a consultation that theyare experiencing difficulties at work with back pain, to give up or findalternative work. The consequences are not discussed and are often devastatingto the individual, especially those with limited transferable skills – Liaise with all health care professionals involved in the case. Beprepared to take a lead in case management. Seek other opinions if you believe thepatient will benefit Summary The causes of low back pain are multifactoral, and management is multimodal.Psychosocial factors strongly influence presentation and outcome at all stagesand are no less important, even in the presence of clearly identifiable spinalpathology. These psychosocial factors, particularly, are amenable to intervention inthe occupational setting. Excellent communication and consulting skills must bea goal for all healthcare professionals. Learning the skills of brief, solution-focusedcounselling will improve your outcomes and job satisfaction. References 1. Waddell G (1998) The Back Pain Revolution. Churchill Livingstone, London 2. Occupational Health Guidelines for the Management of Low Back Pain atWork: Evidence review and recommendations. (2000) Faculty of OccupationalMedicine, London. 3. Buchbinder R, Jolley D, Wyatt M (2001) Population-based intervention tochange back pain beliefs and disability: Three part evaluation. BMJ,322:1516-1520. 4. Symonds TL, Burton AK, Tillotson KM, Main CJ (1995) Absence resultingfrom low back trouble can be reduced by psychosocial interventions at theworkplace. Spine, 20: 2738-2745. 5. Roland M, Waddell G, Moffett JK, Burton AK, Main CJ, Cantrell E, (1997)The Back Book. The Stationary Office, Norwich. Further information Musculoskeletal (orthopaedic) physicians: The British Institute of Musculoskeletal Medicine, 34 The Avenue, Watford,Herts, WD17 4AH 01923 220999, and doctors The Society of Orthopaedic Medicine, 6 Court View Close, Lower Almondsbury,Bristol, BS32 4DW 01454 610255, www.soc-ortho-med.orgWorkshops, seminars and courses on brief, solution-focused effectivecounselling and communication skills: suitable for all healthcareprofessionals: MindFields College, Church Farm, Chalvington, East Sussex, BN27 3TD 01323 811440 Grahame Brown BSc MRCGP DipSportsMed AFOM HGdip FFSEM(RCSI)is amusculoskeletal (orthopaedic) and sports physician and specialist inoccupational and psychological medicine at the Royal Orthopaedic Hospital NHSTrust, Birmingham. He is hon. senior clinical lecturer at The Institute of OccupationalHealth, the University of Birmingham, and consultant to the occupational healthteam at Land Rover vehicles and to a number of professional sports teams andmusicians. He integrates a variety of orthodox and selected complementary treatmentsand therapies into patient management. [email protected] 1: Psychosocial key points– Psychological factors have aconsiderable influence on pain and disability, and a stronger influence onoutcome than biomedical factors– The shift from medical to bio-psychosocial models of illnesshighlights the major importance of psychological factors– Important factors are distress, beliefs and attitudes, painbehaviour and pain-coping strategies– Psychological factors in response to acute pain arepredictive of chronic incapacity– There needs to be a redirection from investigations into thenature of pain towards obstacles to recovery– Distress at and confusion about previous treatments have apowerful influence on a patient’s reaction to pain and disability– There is an urgent need to develop the integration ofpsychological perspectives into the clinical practice of all health careprofessionals– Better management of psychological reactions at early stagesof treatment has the potential to reduce distress and prevent unnecessarychronicityBox 2: Psychosocial warning signsAttitudes and beliefs about pain– Pain is always harmful– Pain must be abolished before return to activity– Catastrophising, ie, thinking the worst, misinterpretingbodily symptoms– Belief that pain is uncontrollable– Passive attitude to rehabilitationBehaviours– Withdrawal from normal activities, substituted withnon-productive time – Poor compliance with exercise. All-or-nothing approach toexercise– Reliance on aids or appliances– Substance abuse, especially smoking and alcoholEmotion– Fear of pain– Depression– Anxiety, irritability, distress, post-traumatic stress– Fear of moving (kinaesiophobia)– Learned helplessness and hopelessness– Anger– All of the above are states of high emotional arousal andwill manifest with sleep disturbance, cognitive impairment (typicallyblack-or-white, all-or-nothing thinking patterns) and physiological symptomsDiagnosis and treatment – Health professionals sanctioning disability– Conflicting opinions and advice, accepting opinions as fact– Behaviour of health professionals, dependency on treatments,over-controlling therapists– Prolonged courses of passive treatments that clearly are notworking– Advice to give up work– Over-reliance on investigations, dramatisation and medicallabelling: ‘arthritis in the spine’, ‘crushed discs’, ‘trapped nerves’, ‘giveup work or you will end up in a wheelchair’Family– Over-protective partner, emphasising fear avoidance andcatastrophising– Solicitous behaviour from spouse– Socially punitive responses from spouse, eg, ignoring– Lack of support– Cultural beliefs and behavioursCompensation issues– Lack of incentive to return to work– History of claims for other health problems– Disputes over eligibility – “How can you get better ifyou have to prove you are ill?”– Persistent focus on ‘diagnosis’ and cause rather restorationof function and health– Ill health retirement benefit issues– Previous experience of ineffective case managementWork– Poor job satisfaction, feels unsupported, frequent job changes– Poor relationship with managers, supervisors, co-workers– Belief that work is harmful– Minimal availability of selected or alternative duties, or agraduated return to work, “Don’t come back until you are totally better”– Low socio-economic status– Job involves significant biomechanical demands– Stress at work: eg, relationships, perceptions, bullyingCase historyAlison, a 50-year old lady, had beenpresenting to health care professionals with back pain and a variety ofdisturbed sensations for the best part of two years. She had had some troublewith her back for many years, but was feeling much more pain now and the painwas gradually getting worse. She was starting to take off a significant amount of time fromher job as a secretary in a large organisation. Spells of absence up to fourweeks at a time were accumulating, totalling 11 weeks during the previous year.She had no symptoms of serious pathology and no nerve rootpain. She had gained weight in the past year. Various courses of physiotherapyhad failed to make any difference to the pain or disability, and blood tests,including thyroid function, arranged by her GP, were negative. The GP did notknow what to do next and asked for an opinion. Importantly, the patient had notcome to the attention of occupational health staff.The patient had been told in the past that she had arthritis inher spine and had been advised to give up swimming, as breast stroke can onlymake this worse (another of the nonsense myths circulating about back pain).Her sleep pattern was very disrupted and she was feeling low in her mood. Heremployer was supportive, but she sensed that this might not always be the case.There did not appear to be any obvious problems at work or at home. I was curious to find out what life events had occurred twoyears ago at the time when she started to present with back pain. It did nottake long to discover that her mother her died. Non-verbal cues indicated thatshe was still grieving and her sleep disturbance had started at the time of herbereavement. Physical examination revealed nothing more than segmentalstiffness in the upper lumbar region.I explained to her that heightened emotional arousal, reflectedin the poor sleep quality, had served to raise her sense of somatic awarenessand lower her tolerance to pain and discomfort. A simple explanation of themind-body system was sufficient to reassure her. I acknowledged her grief andencouraged her to talk more about her feelings with her husband over the comingweeks. Advice to stop exercising and instilling fears of disease had only madematters worse. Her X-rays had merely shown age-related changes. Her back washurting because of excessive muscle tension crimping joints tight and her backwas out of condition. Simple and brief solution-focused counselling on that onevisit was sufficient to break the cycle of pain and depression. I advised herto return to the physical activities that gave her pleasure. I did not think thatany further physical treatments would serve any useful purpose in this case.The whole consultation took no more than 45 minutes.At review six weeks later her depressed mood had lifted, hersleep was refreshing, she was enjoying swimming and her weight was coming off.She was much more positive about her work. And coincidentally, the back painwas now only an ache she could manage with. All her other distressing symptomshad vanished. She felt confident enough to request no further follow up ortreatment.   Related posts:No related photos. Previous Article Next Article Back to workOn 1 Nov 2002 in Musculoskeletal disorders, Personnel Today Comments are closed. last_img read more

Recent Comments