Effects of neuromuscular electrical stimulation in patients with heart failure - review.

Research conducted in the last two decades suggests that neuromuscular electrical stimulation of the lower limb muscles (NMES) may be a "bridge" to conventional exercise or an alternative for patients with advanced chronic heart failure (CHF), non-compliant or non-responsive to physical training. Through stimulating the work of the skeletal muscles, NMES increases the functional capacity, muscle mass and endurance in patients with CHF. A beneficial effect of NMES on functional capacity, vascular endothelial function, quality of life and aerobic enzymes activity has been shown. A significant benefit of this novel therapy in heart failure is the fact that the procedure can be home-based, after prior guidance of the patient.

Short-term Administration of Alphacalcidol is Associated with More Significant Improvement of Muscular Performance in Women with Vitamin D Deficiency Compared to Native Vitamin D.

Introduction: Positive relationships between muscle function and vitamin D (VD) status, defined by serum 25-hydroxy VD (25OHD) levels have been reported and muscle strength is generally improved with VD supplementation in deficient individuals. The effects of active VD analogs have been less studied. Aim: We aim to investigate the effect of short-term treatment with native VD (cholecalciferol) or alphacalcidol on the muscular function and physical performance in women with vitamin D deficiency. Material and methods: We analysed 178 women with VD deficiency, defined as serum 25-hydroxyVD-25OHD concentration below 30 ng/ml. We recorded the grip-strength and the results of the chair-rise test (CRT) and timed-up-and-go test (TUG). We randomised the patients to receive cholecalciferol 1 000 IU daily or alphacalcidol 1 µg daily, for 6 months. Results: The mean baseline 25OHD concentration was 14.47±6.57 ng/ml. After treatment the serum 25OHD level rose to 20.85±8.88 ng/ml, significantly higher in cases supplemented with cholecalciferol (22.7±8.32 ng/ml) compared to those treated with alphacalcidol (13.5±7.29 ng/ml, p=0.000). After treatment, significant improvements of TUG and CRT test results (- 6.48 and-5.05% compared to baseline, respectively, p=0.000) and gripstrength (7.85% compared to baseline, p=0.000) occurred. The benefit was more significant in cases treated with alphacalcidol for gripstrength (p=0.001), TUG (p=0.002), CRT (p=0.033). After treatment, the gripstrength increased significantly more in patients with severe baseline VD deficiency. Conclusions: VD status improvement is associated with an increase in muscular performance in women with VD deficiency. Alphacalcidol exerts significantly better effects compared to cholecalciferol, and this can not be explained by a larger increase in serum 25OHD concentration.

ASSOCIATION BETWEEN LOW BONE MINERAL DENSITY, METABOLIC SYNDROME AND SEX STEROIDS DEFICIENCY IN MEN.

OBJECTIVE: To analyze the association between low bone mineral density (BMD), metabolic syndrome (MS) and sex hormones deficiency in men. METHODS: We included in this retrospective study 199 men with osteoporosis or osteopenia and 167 men with normal BMD as controls, aged between 55-85 years old. Patients' evaluation included: medical history and physical examination, X-ray of thoracic and lumbar spine, measuring BMD at hip and lumbar spine, serum glucose and lipid profile, serum levels of total testosterone (tT), free testosterone (fT) and estradiol (E2). RESULTS: The results revealed a significant association between low BMD and MS (p=0.011). Vertebral fractures were more frequently associated with MS (p=0.041). Patients with MS had lower vertebral BMD (p=0.037) and lower E2 levels (p=0.024) compared with those without MS. In men with MS, E2 deficiency can predict the value of vertebral and hip BMD. fT deficiency can predict only the value of hip BMD. CONCLUSIONS: A significant association between MS, low BMD, vertebral fractures and sex steroids deficiency, in particular E2 and fT was found. The presence of MS and sex hormones deficit can predict the reduction of BMD.

Trigger points--ultrasound and thermal findings.

RATIONALE: Muscle pain can be elicited by any irritation of the nociceptors in the muscle or central sensitization in the central nervous system. The most frequently described muscle pain syndromes are myofascial pain syndrome and fibromyalgia syndrome. Myofascial pain syndrome has a more localized manifestation, the trigger points. OBJECTIVE: If there is a correlation between the clinical findings, the ultrasound examination and the thermal pattern of trigger points exist. MATERIAL AND METHOD: The presence of trigger points can be identified by using clinical criteria. An ultrasound examination was performed to evaluate the trigger point dimensions. The ultrasound showed an ellipsoidal hypoechogenic area in the muscle. A thermography of the low back region was performed in order to observe the thermal pattern of the area. RESULTS: Trigger points are represented by a higher temperature area surrounded by a cooler area, probably caused by a deficit in the blood flow around those points. DISCUSSION: Infrared thermography could be a great asset for the monitoring of neuromusculoskeletal disorders and their dynamics, as well as an important aid for the initial diagnosis of conditions associated with tissue temperature alterations.

Position paper on PRM and persons with long term disabilities.

In the current population we observe a rise of chronic health problems often with multiple characteristics. This results in a growing number of people who are experiencing long-term disabilities or difficulties in functioning because of disability. These conditions require a complex response over an extended period of time, that involves coordinated inputs from a wide range of health professionals. This paper argues the central role and benefit of rehabilitation and describes the rehabilitation as an integral component in the management of people with chronic disabilities. It also presents the most important related definitions: long-term care, rehabilitation for chronic disease and disability, the aim of physical and rehabilitation medicine (PRM). An interdisciplinary team is ideal for an effective implementation of rehabilitation for chronic disease and disability. However, the article mainly focuses on defining the role and contribution of the PRM physician in the rehabilitation of persons with long-term disabilities. The article includes: descriptions of his/her key role and competencies, particularly with regard to medical and functional status and prognosis, of the ability to comprehensively define the rehabilitation needs of the patient/person with respect to ICD-WHO classification domains, of the cooperation with other medical specialists and health professionals, of determining the rehabilitation potential, of developing the rehabilitation plan tailored to specific needs, as well as of the contribution of PRM physician in the follow-up care pathways.

Spinal pain management. The role of physical and rehabilitation medicine physicians. The European perspective based on the best evidence. A paper by the UEMS-PRM Section Professional Practice Committee.

One of the objectives of the Professional Practice Committee (PPC) of the Physical and Rehabilitation Medicine (PRM) Section of the Union of European Medical Specialists (UEMS) is the development of the field of competence of PRM physicians in Europe. To achieve this objective, UEMS PRM Section PPC has adopted a systematic action plan of preparing a series of papers describing the role of PRM physicians in a number of disabling health conditions, based on the evidence of effectiveness of the PRM interventions. The aim of this paper is to describe the role of PRM physicians in the management of spinal pain focusing particularly on low back pain and neck pain. These disorders are associated with significant disability that results in activity limitations and participation restrictions. A wide variety of PRM interventions including patient education, behavioural therapies, exercise, a number of physical modalities, manual techniques, and multidisciplinary rehabilitation may help patients with low back pain and cervical pain in improving their functioning. PRM physicians may address many of the problems encountered by these patients in many life areas taking the International Classification of Functioning, Disability and Health as a reference guide and may have an important role in improving the quality of their lives.

Local soft tissue musculoskeletal disorders and injuries. The role of physical and rehabilitation medicine physicians. The European perspective based on the best evidence. A paper by the UEMS-PRM Section Professional Practice Committee.

One of the objectives of the Professional Practice Committee (PPC) of the Physical and Rehabilitation Medicine (PRM) Section of the Union of European Medical Specialists (UEMS) is the development of the field of competence of PRM physicians in Europe. To achieve this objective, UEMS PRM Section PPC has adopted a systematic action plan of preparing a series of papers describing the role of PRM physicians in a number of disabling health conditions, based on the evidence of effectiveness of PRM interventions. Soft tissue musculoskeletal disorders (MSDs) and injuries are associated with significant pain and loss of function that may lead to significant disability. The aim of this paper is to define the role of PRM physician in the management of local soft tissue MSDs and injuries with their specific focus on assessing and improving function as well as participation in the community. The training of PRM specialists make them well equipped to successfully treat MSDs including soft tissue MSDs and injuries. PRM specialists may well meet the needs of patients with soft tissue MSDs and injuries using PRM approaches including 1) assessment based on the comprehensive model of functioning, the International Classification of Functioning, Disability and Health (ICF), that enable them to identify the areas of impaired functioning in order to apply necessary measures; 2) accurate diagnosis using instrumental diagnostic procedures in addition to clinical examination; 3) outcome measurements available to them; 4) evidence-based pharmacological and nonpharmacological treatments; and finally 5) maintenance of social involvement including "return to work" based on restoration of function, all of which will eventually result in improved quality of life for patients with soft tissue MSDs and injuries.

Shoulder pain management. The role of physical and rehabilitation medicine physicians. The European perspective based on the best evidence. A paper by the UEMS-PRM Section Professional Practice Committee.

One of the objectives of the Professional Practice Committee (PPC) of the Physical and Rehabilitation Medicine (PRM) Section of the Union of European Medical Specialists (UEMS) is the development of the field of competence of PRM physicians in Europe. To achieve this objective, UEMS PRM Section PPC has adopted a systematic action plan of preparing a series of papers describing the role of PRM physicians in a number of disabling health conditions, based on the evidence of effectiveness of the physical and rehabilitation medicine interventions. According to the PCC of the UEMS-PRM Section, the role of PRM physician in the management of shoulder pain (SP) has to be situated inside the general pain management field. SP is a common condition that can place limitations on the activity and restriction in social life participation of sufferers. A variety of shoulder problems, commonly including subacromial impingement, calcifying tendinitis, frozen shoulder, acromio-clavicular disturbances, gleno-humeral instability and gleno-humeral arthritis, can cause pain, and patients should be assessed and treated in order to relieve symptoms and reduce disability. This position paper describes the role of the PRM specialist in the management of such patients. Many assessment methods and treatment interventions are usually used in the management of patients with SP. Depending on the process, disability and patient characteristics, some intervention modalities have reported evidence in pain relief, movement and daily life activity (DLA) restoration, thus permiting a patient early recovery and social participation. Oral medications, local injections, physical therapy modalities and exercises are normally used for the management of SP. The PRM specialist should, always use this best medical evidence to decide how to efficiently and effectively reduce SP-related disability. An adequate therapeutic algorithm is also proposed in order to channelize the above mentioned evidence and reach the best results.

Musculoskeletal perioperative problems. The role of physical and rehabilitation medicine physicians. The European perspective based on the best evidence. A paper by the UEMS-PRM Section Professional Practice Committee.

One of the objectives of the Professional Practice Committee (PPC) of the Physical and Rehabilitation Medicine (PRM) Section of the Union of European Medical Specialists (UEMS) is the development of the field of competence of PRM physicians in Europe. To achieve this objective, UEMS PRM Section PPC has adopted a systematic action plan of preparing a series of papers describing the role of PRM physicians in a number of disabling health conditions, based on the evidence of effectiveness of the physical and rehabilitation medicine interventions. According to the UEMS-PRM section, the role of PRM physician in musculoskeletal perioperative settings has to be situated inside general pain management. Musculoskeletal surgery (MSS) represents a frequent medical situation among patients suffering from musculoskeletal disorders (MSDs), in which PRM physicians need to be involved. A wide number of MSDs have to be operated in order to diminish disability and relieve symptoms, thus improving the patient´s functioning and social participation: Joint replacements, spine decompressions, vertebroplasties, internal fixation of unstable fractures, arthroscopies for tendon and joint repairs, and others. This paper describes the role of the PRM physician during the perioperative period. A well-coordinated rehabilitation programme followed by a good home rehabilitation programme results in pain reduction, faster recovery with better patient participation and increased cost effectiveness. PRM physicians have to identify patients at risk of continuing activity limitation and participation restriction who will benefit from an early rehabilitation process and formulate a PRM programme of care taking into account each patient's environmental factors.

Generalised and regional soft tissue pain syndromes. The role of physical and rehabilitation medicine physicians. The European perspective based on the best evidence. A paper by the UEMS-PRM Section Professional Practice Committee.

One of the objectives of the Professional Practice Committee (PPC) of the Physical and Rehabilitation Medicine (PRM) Section of the Union of European Medical Specialists (UEMS) is the development of the field of competence of PRM physicians in Europe. To achieve this objective, UEMS PRM Section PPC has adopted a systematic action plan of preparing a series of papers describing the role of PRM physicians in a number of disabling health conditions, based on the evidence of effectiveness of PRM interventions. Generalised and regional soft tissue pain syndromes constitute a major problem leading to loss of function and disability, resulting in enormous societal burden. The aim of this paper is to describe the unique role of PRM physicians in the management of these disabling conditions that require not only pharmacological interventions but also a holistic approach including the consideration of body functions, activities and participation as well as contextual factors as described in the ICF. Evidence-based effective PRM interventions include exercise and multicomponent treatment including a psychotherapeutic intervention such as cognitive behavioural therapy (CBT) in addition to exercise, the latter based on strong evidence for reducing pain and improving quality of life in fibromyalgia syndrome (FMS). Balneotherapy, meditative movement therapies, and acupuncture have also been shown as efficacious in improving symptoms in FMS. Emerging evidence suggests the use of transcranial magnetic or direct current stimulation (rTMS or tDCS) in FMS patients with intractable pain not alleviated by other interventions. Graded exercise therapy and CBT are evidence-based options for chronic fatigue syndrome. The use of some physical modalities and manipulation for myofascial pain syndrome is also supported by evidence. As for complex regional pain syndrome (CRPS), strong evidence exists for rTMS and graded motor imagery as well as moderate evidence for mirror therapy. Interventional techniques such as blocks and spinal cord stimulation may also be considered for CRPS based on varying levels of evidence. PRM physicians' functioning oriented approaches on the assessment and management, adopting the ICF as a reference, may well meet the needs of patients with soft tissue pain syndromes, the common problems for whom are loss of function and impaired quality of life. Available evidence for the effectiveness of PRM interventions serves as the basis for the explicit role of PRM specialists in the management of these health conditions.

Inflammatory arthritis. The role of physical and rehabilitation medicine physicians. The European perspective based on the best evidence. A paper by the UEMS-PRM Section Professional Practice Committee.

One of the objectives of the Professional Practice Committee (PPC) of the Physical and Rehabilitation Medicine (PRM) Section of the Union of European Medical Specialists (UEMS) is the development of the field of competence of PRM physicians in Europe. To achieve this objective, UEMS PRM Section PPC has adopted a systematic action plan of preparing a series of papers describing the role of PRM physicians in a number of disabling health conditions, based on the evidence of effectiveness of the physical and rehabilitation medicine interventions. Inflammatory arthritis is a major cause of disability with an important economic burden in society. The goals in the management of inflammatory arthritis are to control pain and disease activity, prevent joint damage, protect and enhance function and improve quality of life. This paper aims to define the role of PRM physicians in people with inflammatory arthritis. PRM interventions imply non-pharmacological treatments which include patient education for joint protection, energy conservation and self-management techniques, exercise therapy, physical modalities, orthoses/assistive devices and balneotherapy. Therapeutic patient education and exercises are the cornerstones of therapy with strong evidence of their effectiveness to improve function. Physical modalities are primarily used to decrease pain and stiffness whereas orthoses/assistive devices are usually prescribed to enhance activities and participation. PRM physicians have distinct roles in the management of people with inflammatory arthritis such that they effectively organise and supervise the PRM program in the context of interdisciplinary team work. Their role starts with a comprehensive assessment of patient's functioning based on the International Classification of Functioning Disability and Health (ICF) as the framework. In the light of this assessment, appropriate PRM interventions individualised for the patient are administered. Future research and actions regarding the role of PRM in inflammatory arthritis should target access to care, updates on the use and effectiveness of physical modalities, orthoses/assistive devices, and standardization of therapeutic patient education programs.

Osteoporosis. The role of physical and rehabilitation medicine physicians. The European perspective based on the best evidence. A paper by the UEMS-PRM Section Professional Practice Committee.

One of the objectives of the Professional Practice Committee (PPC) of the Physical and Rehabilitation Medicine (PRM) Section of the Union of European Medical Specialists (UEMS) is the development of the field of competence of PRM physicians in Europe. To achieve this objective, UEMS PRM Section PPC has adopted a systematic action plan of preparing a series of papers describing the role of PRM physicians in a number of disabling health conditions, based on the evidence of effectiveness of PRM interventions. A wide range of health conditions treated by PRM specialists carries the risk of osteoporosis (OP). The consequences of OP may be associated with significant disability. The aim of this paper is: to define the role of PRM physicians in the prevention and management of OP, to describe the needs of people with OP in relation to rehabilitation strategy, and to highlight why and how PRM physicians should be involved in the diagnosis and management of OP. PRM physicians may intervene in the prevention of and risk factor assessment for OP, falls and fractures along with other assessments of functioning and of quality of life. In addition, they are involved in diagnosis and in both pharmacological and nonpharmacological treatment of OP. From a specific PRM perspective based on the International Classification of Functioning, Disability and Health (ICF), there is an important role in optimizing functioning and promoting "activities and participation", including interventions associated with environmental factors for people with OP or osteoporotic fractures. Evidence suggests that a large number of interventions within the scope of PRM that range from preventive strategies (including education and self management and most importantly exercise) to pain management strategies and spinal orthoses or hip protectors may be effective in the prevention and/or management of OP and its sequelae. Competencies and aptitudes of PRM specialists, focusing especially on functioning while providing care over the whole course of a health condition from the hospital to the community, may well place them in the management of OP. Evidence-based effective PRM interventions further warrant the role of PRM physicians in the management of OP.

Osteoarthritis. The role of physical and rehabilitation medicine physicians. The European perspective based on the best evidence. A paper by the UEMS-PRM Section Professional Practice Committee.

One of the objectives of the Professional Practice Committee (PPC) of the Physical and Rehabilitation Medicine (PRM) Section of the Union of European Medical Specialists (UEMS) is the development of the field of competence of PRM physicians in Europe. To achieve this objective, UEMS PRM Section PPC has adopted a systematic action plan of preparing a series of papers describing the role of PRM physicians in a number of disabling health conditions, based on the evidence of effectiveness of the PRM interventions. Osteoarthritis (OA) is the most common joint disorder and the major cause of musculoskeletal pain and limited mobility in the elderly in the world. Therefore, proper management of persons with OA is of substantial importance. The goal of OA management is to reduce the impact of OA on the individual by reducing pain and improving function, activities and participation. The aim of this paper is to descibe the explicit role of PRM physicians in providing management for persons with OA. The optimal management of OA requires the combination of both non-pharmacological and pharmacological approaches, an issue most of the main guidelines on the evidence-based management of OA share in common. There is good level of evidence about the effectiveness of PRM interventions in the management of OA: high level of evidence about the effect of education, weight reduction and exercise and growing evidence about the effectiveness of physical agent modalities. PRM specialists are involved not only in diagnosis and medical and physical treatments of OA, but, as a rehabilitation strategy, they also deal with the problems of the person focusing on the improvement of all components of human functioning as defined in the ICF including personal and environmental factors with a holistic approach. ICF core sets for OA serve as excellent models for directing proper assessments as well as targeting interventions. PRM specialists well meet the needs of people with OA from the early stages of the disease to the stage of disability that could cause activity limitations and participation restrictions. In conclusion, PRM specialists can make substantial contributions to providing management of OA in order to improve the functioning of individuals with OA from both personal and societal perspective.

Role of the physical and rehabilitation medicine specialist regarding of children and adolescents with acquired brain injury.

Acquired brain injury (ABI) is one of the most common causes of mortality and severe disability in children and adolescents. Those with ABI may suffer any of a wide range of disorders that may limit their activity, their participation in family and school life, and their involvement in society in general. This paper describes the different stages of recovery - hospitalisation, preparing for discharge, and long term follow-up, in which PRM specialists are involved. Although the involvement of the PRM specialist is important in all three stages, it is during the latter two stages when his or her expertise is particularly important. An interdisciplinary care team - which the PRM specialist is well placed to lead ­ is required if the best results are to be achieved.

Dynamic of oxidative and nitrosative stress markers during the convalescent period of stroke patients undergoing rehabilitation.

BACKGROUND: Stroke patients have a redox imbalance, a consequence of both the cerebrovascular event and the associated pathological conditions. Our study was aimed to investigate the dynamic of some oxidative and nitrosative markers during the convalescent phase of postacute stroke patients undergoing rehabilitation. METHODS: We assessed thiol, advanced oxidation protein product, protein carbonyl, 3-nitro-l-tyrosine, ceruloplasmin and oxidized LDL concentrations, as well as gamma-glutamyltranspeptidase (GGT) activity in 20 patients at the beginning of the hospitalization and at the discharge moment, respectively, and 24 apparently healthy controls. RESULTS: We found significantly increased values for GGT (P = 0.04), ceruloplasmin (P = 0.01) and protein carbonyl (P = 0.04) in stroke patients at the hospitalization moment when compared with healthy controls, while total thiols were significantly decreased (P = 0.002). Rehabilitation was associated with a significant decrease of protein carbonyl (P = 0.03) and oxidized LDL particle concentrations (P = 0.03), as well as GGT activity (P = 0.02). At the hospitalization moment, both GGT and ceruloplasmin were significantly negatively correlated with non-proteic thiols (r = -0.44, P = 0.049, and r = -0.53, P = 0.015, respectively) and significantly positively with protein carbonyls (r = +0.80, P < 0.001, and r = +0.69, P < 0.001, respectively) suggesting putative roles of GGT and ceruloplasmin in the redox imbalance. CONCLUSIONS: These results highlight the existence of a redox imbalance in postacute stroke patients, and the possible benefits of an antioxidant-based therapy for the recovery of these patients.

Non-velocity-related effects of a rigid double-stopped ankle-foot orthosis on gait and lower limb muscle activity of hemiparetic subjects with an equinovarus deformity.

BACKGROUND AND PURPOSE: This study investigated the non-velocity-related effects of a 1-bar rigid ankle-foot orthosis on the gait of hemiparetic subjects, with particular emphasis on the muscle activity of the paretic lower limb. METHODS: Twenty-one hemiparetic subjects who had been using an ankle-foot orthosis for equinovarus deformity for <1 week participated. Patients walked cued by a metronome at a comparable speed with and without the orthosis. Dependent variables were basic, limb-dependent cycle parameters, gait symmetry, vertical ground reaction forces, sagittal ankle excursions, and kinesiological electromyogram of several lower limb muscles. RESULTS: The use of the caliper was associated with more dynamic and balanced gait, characterized by longer relative single-stance duration of the paretic lower limb, better swing symmetry, better pivoting over the stationary paretic foot, and better ankle excursions (P<0.05). The functional activity of the paretic quadriceps muscles increased, while the activity of the paretic tibialis anterior muscle decreased (P<0.05). CONCLUSIONS: The orthosis led to a more dynamic and balanced gait, with enhanced functional activation of the hemiparetic vastus lateralis muscle. The study further supports the functional benefits of a rigid ankle-foot orthosis in hemiparetic subjects as an integral part of a comprehensive rehabilitation approach. However, the reduced activity in the tibialis muscle may lead to disuse atrophy and hence long-term dependence on the orthosis.