Groin Pain Syndrome Italian Consensus Conference on terminology, clinical evaluation and imaging assessment in groin pain in athlete.

The nomenclature and the lack of consensus of clinical evaluation and imaging assessment in groin pain generate significant confusion in this field. The Groin Pain Syndrome Italian Consensus Conference has been organised in order to prepare a consensus document regarding taxonomy, clinical evaluation and imaging assessment for groin pain. A 1-day Consensus Conference was organised on 5 February 2016, in Milan (Italy). 41 Italian experts with different backgrounds participated in the discussion. A consensus document previously drafted was discussed, eventually modified, and finally approved by all members of the Consensus Conference. Unanimous consensus was reached concerning: (1) taxonomy (2) clinical evaluation and (3) imaging assessment. The synthesis of these 3 points is included in this paper. The Groin Pain Syndrome Italian Consensus Conference reached a consensus on three main points concerning the groin pain syndrome assessment, in an attempt to clarify this challenging medical problem.

How could robotic training and botolinum toxin be combined in chronic post stroke upper limb spasticity? A pilot study.

BACKGROUND: Spasticity has a role of primary importance in functional motor recovery of upper limb after a stroke. The widespread intervention is the botulinum toxin neurolysis, however robotic training could have a role as useful addition to this conventional therapy. AIM: The aim of this study was to verify how the combination of a short robotic training and chemical neurolysis reduces spasticity and improves function in chronic post-stroke patients. DESIGN: Prospective single blind randomized controlled clinical trial. SETTING: Post-stroke outpatients. POPULATION: Fifteen chronic post-stroke outpatients with severe upper limb spastic paresis. METHODS: Two experimental groups underwent ten sessions of robotic training, alone (Group A) or with Botulinum toxin neurolysis (Group B). Evaluation of motor function with Fugl Meyer Upper Limb Assessment Scale (FMA) and Box & Block Test (B&B), disability with Functional Indipendence Measure (FIM), spasticity with Modified Ashworth Scale (MAS), and the Quality of Life (Euro-Qol) and muscular recruitment pattern with dynamic surface electromyography were carried out before and after the interventions. RESULTS: Both groups showed improvement in FMA (Group A 8.25 and Group B 5.29). Higher improvement in B&B was detected in the group A (2.62 versus 0,14 in Group B). MAS was improved more in the Group B (-0,86 versus -0,14 in Group A). In both groups, sEMG showed a reduction of co-contractions and an increase of agonist muscles recruitment during the reaching movement and the robotic exercises. CONCLUSION: The demonstrated improvement in motor function and in muscular activation pattern suggests how a short robotic training could be effective in chronic post-stroke spasticity of upper limb and in less severe spasticity the only robotic treatment could be effective. CLINICAL REHABILITATION IMPACT: With the limits of small sample, the results showed some equivalence between these two approaches with respect to motor recovery and spasticity reduction suggesting that the cost effectiveness of each treatment may have an important role in this choice.

Is CIMT a rehabilitative practice for everyone? Predictive factors and feasibility.

BACKGROUND: Constraint Induced Movement Therapy (CIMT) in hemiplegic patient is an efficacious method for upper limb rehabilitation. AIM: To verify the applicability of CIMT in post stroke inpatients and to verify the predictive value of some clinical and functional independent variables on the outcomes, in order to identify a population of subjects to which this technique can be more effective. DESIGN: Non-controlled clinical study. SETTING: Seven Italian, non-experimental, Rehabilitation Departments. MATERIALS AND METHODS: All post-stroke inpatients (subacute and chronic), consecutively admitted in 7 Rehabilitation Departments, were screened according to our inclusion criteria. The eligible population was assessed according to selected clinical and functional variables at the baseline, and it was evaluated with Wolf Motor Function Test (WMFT-FAS and WMFT-PTT) and Motor Activity Log (MAL-AOU and MAL-QOM), before treatment (T0), after treatment (T1) and at a 3-month follow up (T2). Patients underwent 2 weeks of CIMT from T0. RESULTS: Of the 600 inpatients screened, 44 were admitted in the CIMT protocol and were evaluated at T0 and T1; just 24 completed the assessment at T2. At the end of treatment NIHSS and Motricity Index (MI) were predictive factors of MAL scores, while Geriatric Depression Scale (GDS), Modified Barthel Inedx (MBI) and MI were predictive factors of WMFT scores. At the follow up NIHSS and GDS remained predictive factors of MAL scores, and MBI was predictive of WMFT FAS score. CONCLUSION: CIMT efficacy did not result to be related to patient's age, mild cognitive deficit, time since stroke. Depression and pinch ability are the main predictors of motor recovery. Despite the demonstrated efficacy, CIMT feasibility still needs to be demonstrated, considering the low percentage (6.5%) of eligibility among all stroke inpatients. CLINICAL REHABILITATION IMPACT: CIMT requires high costs and resources; therefore it is valuable to know the predictive factors which help select the eligible patients. It is then useful to recognize the risk factors of developing Learned Non Use after stroke.

Cardiorespiratory comorbidity: a new challenge for physical and rehabilitation medicine specialist.

BACKGROUND: The cardiorespiratory comorbidity can reduce the participation in the rehabilitation project of patients with motor disorders. AIM: The first aim of the study was to assess the frequency of cardiopulmonary comorbidity in inpatient rehabilitation units in Italy. The second aim was to evaluate the influence of cardiorespiratory comorbidity on some process and outcome indicators. DESIGN: Data collection with a questionnaire sent to Physical and Rehabilitation Medicine specialists. SETTING: Inpatient Rehabilitation Units. POPULATION: Patients admitted to Rehabilitation Units with neurological and orthopedic disability. METHODS: A questionnaire was sent to 33 Rehabilitation Units in Italy. OUTCOME: Length of stay in hospital (LOS), percentage of transfer to acute wards, level of satisfaction of the Physicians related to the degree of functional recovery of patients with cardiopulmonary comorbidity. In a subgroup of patients with and without cardiopulmonary comorbidity indicators were also used to retrospectively assess functional recovery during the hospitalization. RESULTS: Analysis were made on 16 complete responses received. Data of 909 subjects were evaluated. The mean incidence of cardiovascular and respiratory diseases is high: 61.50%. The length of hospitalization (LOS) in patients with cardiac and respiratory comorbidity is significantly longer than in subjects without associated disease (46.55, SD 21.00 days vs. 37.26, SD 18.97; P<0.05). The number of transfers to acute wards is significantly higher in subjects with cardiorespiratory comorbidity (8.62% vs. 2.44%; P<0.05). Eleven out of 16 medical doctors (69%) said they were "quite satisfied" for the degree of functional recovery of patients with comorbidity. A group of patients with neurological disabilities associated with cardiorespiratory disease had significantly lower Functional Independence Measure (FIM) score at admission (55.36, SD 20.62, vs. 73.72, SD 22.15; P<0.05) than these without comorbidity. At discharge the subjects of the two groups assessed, independently from the presence of cardiorespiratory comorbidity, present no statistically significant difference of FIM scale values. CONCLUSION: The high frequency of cardiorespiratory comorbidity in patients with motor disorders negatively influenced the LOS and percentage of transfer to acute wards but not necessarily the functional results. It is, therefore, necessary to train the medical doctor who specializes in physical and rehabilitation medicine also in the clinical management of complex patients. CLINICAL REHABILITATION IMPACT: The results of the survey suggest that rehabilitation is useful even in patients with motor disorders and cardiorespiratory comordibity.

The constraint induced movement therapy: a systematic review of randomised controlled trials on the adult stroke patients.

AIM: The aim of this study was to analyse the evidence of effectiveness on adult stroke patients of the Constraint Induced Movement Therapy (CIMT), an original rehabilitation method that consists in strongly encouraging patients to use the affected arm, mainly immobilising the unaffected arm. METHODS: We only took into account the randomised controlled trials on CIMT where the experimental treatment was compared with a conventional treatment without any discrepancy of organization or session duration. As we could not measure the statistical significance of differences between treated and control patients, we compared their respective post-treatment percent changes and computed the minimal clinically important difference (MCID), defined as a change of at least 10% of the maximum score of the scale used. RESULTS: The literature search found 13 randomised controlled trials (RCTs), 4 of which were excluded because they aimed at comparing different intensity of CIMT. The 9 RCTs finally included into the review applied the CIMT in either acute, subacute or chronic stroke patients and according to different modalities. Findings were positive in all studies, but the MCID was reached only in smaller ones, which may have been influenced by patients' characteristics. CONCLUSION: Although all studies achieved positive results, it is impossible to draw any clear-cut conclusion on the effectiveness of the CIMT. The main limitations are the lack of homogeneity in the outcome measures used, the inadequacy of data provided and the small samples' size. Multicentre studies, using robust outcome measures and considering both motor- and sensory-disabled patients are needed.

The conclusions of the systematic revision with the results from the major clinical and experimental studies.

In this issue, we would complete the conclusions of the systematic revision with the results from the major clinical and experimental studies. First of all, we outline that the use of bone mineral density is controversial and opposed of the major studies in the field that show that the bone density is only one of the factors which describe bone resistance, and not the bone quality. In fact, often, a dramatic variation of bone strength is linked to the fact that the newly bone is located in the only in the surfaces where mechanical stress is greatest and this doesn't change completely the density. To study the optimal exercises program we have to remember that the ideal timing in the remodelling unit of the bone was estimated at 4-6 months: therefore any treatment which has the aim of preventing bone loss should last at least 2-3 times this period to ensure that the registered effect on bone density is evaluated in a period of balance. According to Frost, the strength of the bone is determined by 4 factors: the mechanical property characteristic of bony tissue, the amount of micro damage from fatigue, bone mass factors (amount and type of bone in the bone) and the size and shaper of the bone (architectural factors). Moreover, it is very important the role of muscular strength on the bone: the muscles work like a lever in such a manner that to move every kilo of body weight, the muscular force is usually over 2 kg. This explains why strong muscles are usually associated with strong bones. About the specific role of the strain on the bone, from studies of the past 10 years there seems to be more precise and useful information for our queries: new formation of bone took place in rabbits only with dynamic stimuli and not static, and it is very important also the frequency of the stimulus and the speed. Moreover, some authors have shown that the stimuli of ostegoenesis depends on the fluid shear stresses though the lacunar-canalicular network system. So: exercises at high impact which can produce significant deformation of the bone matrix, better carry the fluid through the canalicular network and furthermore the strains applied at high frequency stimulate in a effective manner osteogenesis. Therefore, the mechanical strain necessary to begin osteogenesis decreases with the increase of the frequency of the strain. Rubin and Lanyon have shown that the prolongation of the stimulation with strain the osteogenic response did non increase if the regimen is prolonged more. In fact, Turner demonstrated that the bone presents a phenomenon of desensitisation following a prolonged strain stimulus. He proposed the osteogenic index of exercises like the osteogenic response to exercise which could be increased in a regimen of exercises which foresee also a period of rest between brief sessions of significant strain. So, concerning the effects of exercises, the stimulus produced by the strain must be such that it exceeds a threshold of a minimum effective stimulus, must be applied in a intermittent and dynamic manner, should produce a stimulus which is distributed differently to the norm, should be applied with high speed and few repetitions.

Manual autotraction: preliminary study on the effectiveness of a new device for back pain treatment.

AIM: The aim of this study is to assess the efficacy of a new, simple and cheap device of manual autotraction (MAT), in comparison with Natchev's autotraction system. METHODS: Fifty-four patients, with lumbalgia or sciatalgia for more than 4 months and disc herniation or protrusion at computed tomography (CT) or nuclear magnetic resonance (NRM), have been selected, at random, in a randomized control trial. Patients have been treated by MAT or by Natchev's autotraction. Treatments' efficacy has been assessed through the differences in visual analogic scale (VAS) for pain, and Backill scale for disability, before and after therapy (diffVAS and diffBi). The results of the 2 autotraction's devices have been compared in order to distinguish their differences. The results have been considered significant if p<0.05. RESULTS: Both treatments proved to be effective (MAT: diffVAS p<0.0001, diffBackill p<0.001; Natchev's group: diffVAS p<0.0001, diffBackill p<0.001). No significant difference of efficacy emerges between the treatments in diffVAS (p=0.199) and diffBi (p=0.906), and a greater efficacy of both in case of pain with nocturnal aggravation (MAT group: diffVAS: p=0.001; Natchev's group: p=0.001). CONCLUSIONS: The results of this study show an equal efficacy of MAT compared to the known Natchev's system, so it could be equally proposed like a simple conservative treatment in disc protrusion or herniation without surgery indication.

Exercise for preventing and treating osteoporosis in postmenopausal women.

BACKGROUND: Osteoporosis is a condition resulting in an increased risk of skeletal fractures due to a reduction in the density of bone tissue. Prevention of osteoporotic-related fractures is dependent on the ability to detect individuals with low bone mass, including those women who are asymptomatic. Treatment of osteoporosis involves the use of either anti-resorptive (e.g. estrogen and bisphosphonate) or bone formation agents (e.g. fluoride and PTH). The value of exercise as an intervention for the prevention of postmenopausal bone loss is a controversial subject. OBJECTIVES: To examine the effectiveness of exercise therapy at preventing bone loss and fractures in postmenopausal women. SEARCH STRATEGY: We searched the Cochrane Musculoskeletal Group's specialised register, MEDLINE, EMBASE, Current Contents and the Cochrane Controlled Trials Registry up to January 2000 according to the methods suggested by Dickersin et al and Haynes et al and the Cochrane Handbook. We hand searched reference lists and consulted content experts. SELECTION CRITERIA: This review was proceeded by a peer reviewed protocol published in the Cochrane Library. Two reviewers independently selected all randomized controlled trials (RCTs) which met our predetermined inclusion criteria. DATA COLLECTION AND ANALYSIS: The same two reviewers abstracted the data using predetermined forms and assessed trial quality using a validated assessment tool. For dichotomous outcomes (fractures), relative risks were calculated using fixed effects models. For continuous data, weighted mean differences (WMD) of the percentage change from baseline were calculated. Where heterogeneity existed (determined by a chi square test), a random effects model was used. MAIN RESULTS: Eighteen randomized controlled trials (RCTs) met the inclusion criteria. The trials had a mean methodological quality score of 2.53. Aerobics, weight bearing and resistance exercises were all effective on the BMD of the spine. The WMD for the combined aerobics and weight bearing program on the spine was 1.79 [95%CI (0.58, 3.01)]. The analyzed results showed walking to be effective on both BMD of the spine 1.31[95%CI (-0.03, 2.65) and the hip 0.92[95%CI (0.21, 1.64). Aerobic exercise was effective in increasing BMD of the wrist 1.22[95%CI (0.71, 1.74)]. REVIEWER'S CONCLUSIONS: Aerobics, weight bearing and resistance exercises are all effective in increasing the BMD of the spine in postmenopausal women. Walking is also effective on the hip. The quality of the reporting of the trials in the meta-analysis was low, in particular, in the areas of allocation concealement and blinding.

Clinical trials among worker populations: the value and significance of anamnestic findings and clinical and instrumental tests for diagnosing work-related musculoskeletal disorders of the upper limbs (WMSDs).

The authors discuss the value and significance of symptoms in WMSDs, in view of the fact that the anamnestic threshold proposed in epidemiological investigations cannot be used as clinical and diagnosing criteria. Some useful clinical procedures are suggested for cases where there is a suspicion of musculoskeletal disorders of the cervical spine and upper limbs, bearing in mind that they are to be applied within the framework of health surveillance programmes undertaken by health care practitioners who are not specialists in orthopaedics, physiatrics or neurology. The recommendations for instrumental tests and specialist referrals are also discussed for the various disorders. The authors also provide flow charts for the diagnostic procedures pertaining to WMSDs. The appendix shows a sample patient chart illustrating the proposed procedures; it also permits the findings to be encoded so that they can be stored in a dedicated database. The codes for diagnosing WMSDs are also reported for the same epidemiological purposes.

[Sacralization of the 5th lumbar vertebra and backache: what's the possible relationship?]. / Sacralizzazione della 5a vertebra lombare e lombalgia: quale rapporto possibile?

Transitional vertebrae is a controversial problem in occupational health and in forensic medicine, in view of its prognostic value and especially because of the implications of law 626/94 which requires a worker assessment for manual handling tasks. The purpose of this review was to assess the relationship between transitional vertebrae and low back pain. Data sources comprised computer-aided search of published studies on Medline and Embase. There were seven studies evaluating the prevalence of the abnormality, the relationship with low back pain and the different aspects of spinal degeneration. Only two studies indicated a positive relationship with low back pain. Four studies reported absence of any prognostic value of this vertebral abnormality. One study examined a twenty year old population: even if it did not show a relationship with a higher incidence of disc degeneration with MRI, we did not include it in our review because of the young age of the samples. It is concluded that present knowledge does not reveal any correlation between transitional vertebrae and low back pain. Further studies are needed to support any conclusion about this important issue.

The affective dimension of low-back pain: its influence on the outcome of back school.

OBJECTIVE: Back School is a rehabilitation treatment for back pain that requires patients to understand an educational message and motivate themselves to modify their behavior to prevent relapses. In examining failed cases, the question arose as to whether the failures could be attributed to affective dimensions of pain that could be reducing tolerance to the pain itself and jeopardizing patients' compliance. We studied the role of the affective component of back pain in Back School failures to see whether this component can be used to predict the treatment's negative results and whether it can be conditioned by the treatment itself. DESIGN: Inception cohort. SETTING: Forty-two subjects with low back pain were treated with Back School at our rehabilitation department. MAIN OUTCOME MEASURES: Evaluation was carried out before Back School treatment and after 2 months, through functional clinical examination and Short Form-McGill Pain Questionnaire (affective and sensory pain indexes). RESULTS: As outcome of the treatment, we considered the modification of spontaneous and evoked pain and the motility of the spine. Unexpectedly, the nonparametric tests did not show a significant correlation between the affective indicators before and after the treatment. As expected, the two dimensions of pain, affective and sensory, are significantly related to each other, both before and after treatment, but this correlation increases after treatment (from r = .50 to r = 88). CONCLUSIONS: The initial hypothesis was not proven. These results show that high affective scores before Back School do not influence the success of the treatment and that the Back School itself is able to modify both the sensorial and affective pain descriptors.

[Clinical studies in working populations: value and significance of anamnestic findings, clinical tests and instrumental tests for the diagnosis of musculoskeletal disorders of the upper extremities]. / Studi clinici in popolazioni lavorative: valore e significato dei rilievi anamnestici, dei test clinici e degli esami strumentali per la diagnosi delle affezioni muscolo-scheletriche degli arti superiori (WMSDs).

The authors discuss the value and significance of symptoms in WMSDs, considering that the anamnestic threshold proposed in epidemiological investigations cannot be used as clinical and diagnosing criteria. Some useful clinical procedures are suggested for cases where there is a suspicion of musculo-skeletal disorders of the cervical spine and upper limbs, bearing in mind that they are to be applied within the framework of health surveillance programmes undertaken by health care practitioners who are not specialists in orthopaedics, physiatrics or neurology. The recommendations for instrumental tests and specialist referrals are also discussed for the various disorders. The authors also provide flow charts for the diagnostic procedures pertaining to WMSDs. The Appendix shows a sample patient chart illustrating the proposed procedures; it also permits the findings to be encoded so that they can be stored in a dedicated database. The codes for diagnosing WMSDs are also reported for the same epidemiological purposes.

[Diseases of the dorsal-lumbar spine and manual handling of loads: guidelines for fitness assessment]. / Patologie del rachide dorso-lombare e movimentazione manuale di carichi: orientamenti per la formulazione di giudizi di idoneità.

In occupational medicine, degenerative diseases and malformations of the spine are one of the main reasons for requests for fitness assessment for specific jobs, especially among workers involved in manual handling tasks. By means of a selected review of the specialised literature, the authors identify analysis procedures and precise criteria for assessing compatibility between the clinical condition of the spine and manual handling tasks. Attention is drawn in particular to the diseases caused or at least aggravated by mechanical overloading of the spine. For each of these a set of diagnostic criteria is established which could be useful in defining the various levels of severity. On another front, by using tried and tested methods and criteria to identify the weight limits that can be lifted by healthy subjects in various manual handling situations, an approach was developed that can be applied to establish the weight limits that can be lifted by subjects with spinal diseases. By combining the two factors, risk level and damage level, a set of disorders was established that correspond to three different fitness levels. At each level, manual load handling was only allowed up to certain weights and for handling conditions that became increasingly stringent as the severity of the disorder increased. The paper outlines the clinical protocols and the protocols for reconstructing work exposure. The procedural differences involved in the case of fitness assessments in the pre-employment stage are also briefly discussed.

[The assessment of the lumbago patient in the work environment: the diagnostic aspects and forensic medical reflections]. / La valutazione del soggetto lombalgico in ambito lavorativo: aspetti diagnostici e riflessi medico legali.

In occupational health the assessment of subjects suffering from lumbago in the case of job fitness certificates is complicated not only because of the obvious possibility of the influence of simulation, but also because of the poor specificity of diagnostic possibilities for spinal disorders. An assessment was made of the reliability of traditional clinical procedures and the most common protocols and the possibility of using them in this context.