Enoxaparin for VTE thromboprophylaxis during inpatient rehabilitation care: assessment of the standard fixed dosing regimen.

BACKGROUND: We aimed to examine the efficiency of fixed daily dose enoxaparin (40 mg) thromboprophylaxis strategy for patients undergoing inpatient rehabilitation. METHODS: This was an observational, prospective, cohort study that included 63 hospitalized patients undergoing rehabilitative treatment following sub-acute ischemic stroke (SAIS) or spinal cord injury (SCI), with an indication for thromboprophylaxis. Anti-Xa level measured three hours post-drug administration (following three consecutive days of enoxaparin treatment or more) was utilised to assess in vivo enoxaparin activity. An anti-Xa level between 0.2-0.5 U/ml was considered evidence of effective antithrombotic activity. RESULTS: We found sub-prophylactic levels of anti-Xa (<0.2 U/ml) in 19% (12/63). Results were within the recommended prophylactic range (0.2-0.5 U/ml) in 73% (46/63) and were supra-prophylactic (>0.5 U/ml) in 7.9% (5/63) of patients. Anti-Xa levels were found to inversely correlate with patients' weight and renal function as defined by creatinine clearance (CrCl) (p<0.05). CONCLUSIONS: Our study confirmed that a one-size-fits-all approach for venous thromboembolism (VTE) prophylaxis may be inadequate for rehabilitation patient populations. The efficacy of fixed-dose enoxaparin prophylaxis is limited and may be influenced by renal function and weight. This study suggests that anti-Xa studies and prophylactic enoxaparin dose adjustments should be considered in certain patients, such as those who are underweight, overweight and or have suboptimal renal function. TRIAL REGISTRATION: No. NCT103593291, registered August 2018.

Consistency of inconsistency in long-COVID-19 pain symptoms persistency: A systematic review and meta-analysis.

INTRODUCTION: Individuals recovering from acute COVID-19 episodes may continue to suffer from various ongoing symptoms, collectively referred to as Long-COVID. Long-term pain symptoms are amongst the most common and clinically significant symptoms to be reported for this post-COVID-19 syndrome. OBJECTIVES: This systematic review and meta-analysis aimed to evaluate the proportions of persisting pain symptoms experienced by individuals past the acute phase of COVID-19 and to identify their associated functional consequences and inflammatory correlates. METHODS: Two online databases were systematically searched from their inception until 31 March 2022. We searched primary research articles in English, which evaluated individuals after laboratory-confirmed COVID-19 acute phase resolution and specifically reported on pain symptoms and their inflammatory and/or functional outcomes. RESULTS: Of the 611 identified articles, 26 were included, used for data extraction, and assessed for their methodological quality and risk of bias by two independent reviewers. Pain symptoms were grouped under one of six major pain domains, serving as our primary co-outcomes. Proportional meta-analyses of pooled logit-transformed values of single proportions were performed using the random-effects-restricted maximum-likelihood model. An estimated 8%, 6%, 18%, 18%, 17%, and 12% of individuals continued to report the persistence of chest, gastrointestinal, musculoskeletal joint, musculoskeletal muscle, general body, and nervous system-related pain symptoms, respectively, for up to one year after acute phase resolution of COVID-19. Considerable levels of heterogeneity were demonstrated across all results. Functional and quality-of-life impairments and some inflammatory biomarker elevations were associated with the persistence of long-COVID pain symptoms. CONCLUSION: This study's findings suggest that although not well characterized, long-COVID pain symptoms are being experienced by non-negligible proportions of those recovering from acute COVID-19 episodes, thus highlighting the importance of future research efforts to focus on this aspect.

Cogstate Brief Battery: Cognition and the feigning of cognitive impairment in chronic pain.

Chronic pain (CP) is often associated with cognitive impairment. The Cogstate Brief Battery (CBB), a computerized assessment battery, has been studied in several neuropsychiatric disorders but not in CP. Since feigning of cognitive impairment is common in CP, the current study aimed to assess the CBB's utility in differentiating CP patients (n = 64) from healthy participants (n = 33), as well as to assess the effect of simulating cognitive impairment by CP patients on performance in the battery. CP outpatients were randomly assigned to one of two groups: (a) Patients performing the CBB to the best of their ability. (b) Patients simulating cognitive impairment. Independent-samples t-tests indicated that three of four CBB tasks successfully differentiated CP patients from matched healthy controls. Additionally, an analysis of covariance (ANCOVA) indicated that CP patients who simulated cognitive impairment performed more poorly in all four CBB tasks, with the detection task having the strongest discrimination capacity. This is the first study to point toward the usefulness and sensitivity of the CBB for assessment of cognition and detection of feigned cognitive impairment in CP. Further studies are required to validate these preliminary findings and assess the CBB's utility in daily clinical practice.

Additive Analgesic Effect of Transcranial Direct Current Stimulation Together with Mirror Therapy for the Treatment of Phantom Pain.

OBJECTIVE: Current analgesic treatments for phantom pain are not optimal. One well-accepted yet limited nonpharmacological option is mirror therapy, which is thought to counterbalance abnormal plasticity. Transcranial direct current stimulation (tDCS) is an emerging approach believed to affect the membrane potential and activity threshold of cortical neurons. tDCS analgesic effectiveness, however, is mild and short, rendering it a noneffective stand-alone treatment. This study aimed to assess if a combination of mirror therapy with tDCS results in a superior analgesic effect as compared with mirror therapy alone in patients suffering from phantom pain due to recent amputation. DESIGN: Following ethical approval, eligible patients provided informed consent and were randomly assigned to a study treatment group that continued for 2 weeks (once daily): 1) mirror therapy; 2) mirror therapy and sham tDCS; or 3) mirror therapy and tDCS. Assessments were done before treatment; at the end of treatment weeks 1 and 2; and at 1 week, 1 month, and 3 months following treatment. The primary outcome measure was pain intensity. Secondary measures were derived from the Short Form McGill Pain Questionnaire and the Brief Pain Inventory. RESULTS: Thirty patients were recruited, and 29 patients completed the study. Three months following treatment, pain intensity was significantly (P<0.001) reduced in the combined treatment group (reduction of 5.4±3.3 points) compared with the other study arms (mirror therapy, 1.2±1.1; mirror therapy and sham tDCS, 2.7±3.2). All secondary outcome results were in line with these findings. CONCLUSIONS: Combining tDCS with mirror therapy results in a robust long-lasting analgesic effect. These encouraging findings may contribute to the understanding of the underlying mechanisms of phantom pain.

A Preliminary Study of Dual-Task Training Using Virtual Reality: Influence on Walking and Balance in Chronic Poststroke Survivors.

BACKGROUND: Stroke is a leading cause of death and disability in the Western world, and leads to impaired balance and mobility. OBJECTIVE: To investigate the feasibility of using a Virtual Reality-based dual task of an upper extremity while treadmill walking, to improve gait and functional balance performance of chronic poststroke survivors. METHODS: Twenty-two individuals chronic poststroke participated in the study, and were divided into 2 groups (each group performing an 8-session exercise program): 11 participated in dual-task walking (DTW), and the other 11 participated in single-task treadmill walking (TMW). The study was a randomized controlled trial, with assessors blinded to the participants' allocated group. Measurements were conducted at pretest, post-test, and follow-up. Outcome measures included: the 10-m walking test (10 mW), Timed Up and Go (TUG), the Functional Reach Test (FRT), the Lateral Reach Test Left/Right (LRT-L/R); the Activities-specific Balance Confidence (ABC) scale, and the Berg Balance Scale(BBS). RESULTS: Improvements were observed in balance variables: BBS, FRT, LRT-L/R, (P < .01) favoring the DTW group; in gait variables: 10 mW time, also favoring the DTW group (P < .05); and the ABC scale (P < .01). No changes for interaction were observed in the TUG. CONCLUSIONS: The results of this study demonstrate the potential of VR-based DTW to improve walking and balance in people after stroke; thus, it is suggested to combine training sessions that require the performance of multiple tasks at the same time.

Efficiency of Tissue Penetration by Currents Induced by 3 Electrotherapeutic Techniques: A Comparative Study Using a Novel Deep-Tissue Measuring Technique.

BACKGROUND: Electrotherapy provides a wide range of treatment alternatives for musculoskeletal pathologies. However, for the electrical stimulation to exert a significant therapeutic effect, the induced current must often penetrate deep inside the target tissue. OBJECTIVE: The objective was to systematically compare the penetration efficiency of 3 electrotherapeutic stimulation modalities: transcutaneous electrical nerve stimulation (TENS), interferential (IF) stimulation, and combined therapy with pulsed ultrasound and IF current (CTPI). DESIGN: This was a comparative, experimental laboratory study. METHODS: The penetration efficiency was evaluated as a voltage difference between 2 of an 8-contact spinal cord stimulation array. Each of 20 participants with a preimplanted spinal cord stimulation array was stimulated with TENS (3 different electrode configurations), IF current (3 configurations), and CTPI (1 configuration). RESULTS: Significant differences in penetration efficiency were found between the various stimulation conditions and electrode configurations. CTPI showed the highest penetration efficiency, followed by IF, and finally TENS. Penetration efficiency was inversely and significantly correlated with skinfold thickness in all conditions, but this correlation was lowest for the CTPI stimulation. LIMITATIONS: Our study design did not include a condition of combined therapy with pulsed ultrasound and TENS, and it did not directly control for current or voltage density under the stimulating electrodes. In addition, further research is required to determine whether a higher stimulation intensity of the target tissue is advantageous clinically. CONCLUSIONS: Pending further testing, CTPI stimulation could prove more effective than IF and TENS in reaching deeper tissues, especially considering the variability in adipose tissue thickness in the population, for example, in cases of patients with obesity.

Deficient Pain Modulation in Patients with Chronic Hemiplegic Shoulder Pain.

BACKGROUND: Hemiplegic shoulder pain (HSP) following stroke significantly affects the individual's function and quality of life. The mechanism of HSP is not clearly understood; hence, it is unclear why HSP resolves spontaneously or following routine care in some patients, while in others it becomes persistent. The aim was therefore to study whether HSP is associated with deficient pain modulation. METHODS: Thirty post-stroke patients-16 with HSP and 14 without HSP-and 20 matched controls participated. Pain adaptation and conditioned pain modulation (CPM) were measured as indicators of pain modulation, in the affected (hemiplegic) and contralateral shoulder as well as in the affected shin among post-stroke patients, and in comparable body regions among controls. Post-stroke patients also underwent functional and physical evaluation of the shoulder. RESULTS: Pain adaptation was absent among HSP patients, in both the painful shoulder and the affected shin, but existed in the 2 control groups. In addition, the affected shoulder and shin among the HSP group had reduced thermal sensibility compared to the contralateral regions. CPM was similar across groups. Shoulder functional status and physical status were similar for the 2 post-stroke groups. CONCLUSIONS: The results suggest that HSP is associated with a lack of pain adaptation, characteristic not only of the painful shoulder but also of the affected side. Although we cannot determine whether lack of pain adaptation precedes the HSP or results from it, interventions that enhance descending pain inhibition may improve management and prevent HSP chronification.

The local and referred pain patterns of the longus colli muscle.

The longus colli muscle is a neck flexor believed to play an important role in pain originating in the neck region, including pain resulting from whiplash injuries. Despite the clinical importance attributed to it, the pain referral pattern of the longus colli has previously been described only in a small cohort of subjects. Here, we aim to delineate the pain referral pattern of the longus colli muscle. Thirty-five healthy volunteers underwent deep massage of the longus colli followed by dry needling of the muscle. The subjects depicted the distribution of the pain they experienced on a blank manikin. Their drawings were digitized and used to produce pain pattern histogram maps. The pain referral pattern during deep massage and needling of the longus colli was primarily local, with referral to the ipsilateral ear and lateral to the ipsilateral eye. Some subjects reported pain on the contralateral side of the neck.

Does pain take holidays? Non-attendance rates at a hospital-based pain clinic are elevated during the Jewish high-holidays.

BACKGROUND: Patient non-attendance is an expensive and persistent problem worldwide with rates between 5-39% reported in the literature. The objective of the study was to assess whether there is a higher incidence of non-attendance in a hospital-based pain clinic during the period of the Jewish High Holidays (Rosh-Hashanah to Sukkot) and whether this is further compounded by other factors, such as demographic characteristics and previous visits to the clinic. METHODS: Records were taken from the Lowenstein Rehabilitation Hospital appointment scheduling system. Data was gathered from two time-periods: High-Holidays and Control for each year, over a total of 6 years 2008-2013. Non-attendance was analyzed by period, by age, by gender and by previous visits to the clinic. RESULTS: In the entire population studied (666 distinct records), the non-attendance rate was higher during the High-Holidays as compared to the Control period (32 vs. 24.1%; p = 0.030). Non-attendance rates were significantly higher during the Holidays among repeating patients (28.6 vs. 14.8%; p = 0.002) and among women (34.6 vs. 20.7%; p = 0.004). DISCUSSION: Our data suggest that non-attendance is elevated during the High-Holidays in specific groups of patients, namely, repeating patients and women. Despite no direct inquiry into the reasons for non-attendance, we speculate that the elevated well-being and familial support during the holidays contribute to the patients' ability to cope with persistent pain and possibly directly reduce the amount of pain, leading to patients missing their pain clinic appointments. CONCLUSION: Our results, provided they can be corroborated by larger-scale studies, can assist in scheduling policy adjustments such as avoidance of appointments during the High-holidays for specific patient populations and more rigorous reminder efforts during these times of the year that may lead to reduction in overall non-attendance rates in the pain clinic. Further, our data provide an impetus for further studies of non-attendance patterns among pain clinic patients, in order to acquire a better understanding of the reasons for non-attendance and develop strategies to reduce it and thus contribute to the continuous improvement of the Israeli health systems as well as others worldwide.

Position Statement of the Israeli Society for Musculoskeletal Medicine on Intramuscular Stimulation for Myofascial Pain Syndrome-A Delphi Process.

OBJECTIVE: To develop consensus on a position paper on the use of intramuscular stimulation (IMS) for the treatment of myofascial pain syndrome (MPS) by physicians in Israel. METHODS: The Israeli Society of Musculoskeletal Medicine ran a modified Delphi process to gather opinions from a multidisciplinary expert panel. Eight experts in the treatment of MPS were chosen and asked to participate, and six participated. The position paper was iterated three times. RESULTS: After three iterations, general consensus was reached by all six experts. The general statement that was agreed on was: "IMS is one of the preferred treatments for myofascial pain syndrome. The treatment is evidence-based, effective, safe, and inexpensive. The position of the Israeli Society of Musculoskeletal Medicine is that the treatment should be taught and used by all primary care physicians and those physicians in other areas of medicine who deal with pain in their work." CONCLUSIONS: The position paper is a basis for clinical work and education programs for physicians interested in a better understanding and ability to treat patients with a musculoskeletal complaint or manifestation of disease.

Effect of kinesio tape application on hemiplegic shoulder pain and motor ability: a pilot study.

The aim of our single-group pre-post design pilot study was to evaluate the short-term effect of kinesio taping (KT) application on pain and motor ability of hemiplegic shoulder pain (HSP) patients. Eleven poststroke patients with HSP hospitalized in the Department of Neurology C, Loewenstein Rehabilitation Hospital, Raanana, Israel, received a KT application in addition to their usual rehabilitation protocol. KT, consisting of one to three strips according to a predefined algorithm, was applied to the painful shoulder region. A 10 cm Visual Analog Scale of shoulder pain at rest and at arm movement, active and passive pain-free abduction range of motion, Box & Blocks, and Fugl-Meyer upper extremity motor assessment were performed before treatment and 24 h after wearing the KT. After applying the KT, there was no significant change in any variables. Short-term KT application, used in our study, produced no change in shoulder pain, range of motion, or ability of upper limb in HSP patients. Additional studies should evaluate the effect of long-term application and different types of KT applications on HSP.

Trends in Physical Medicine and Rehabilitation Publications Over the Past 16 Years.

OBJECTIVES: To test the hypothesis that the number of publications in the field of physical medicine and rehabilitation (PMR) has increased over the last 16 years in a linear fashion, and to compare the trends in publication between the pediatric and adult literature. DESIGN: We evaluated all MEDLINE articles from January 1, 1998, to December 31, 2013, using Medical Subject Headings categories of rehabilitation. An age filter separated adult and pediatric articles. We divided articles into those with a low level of scientific evidence such as letters and editorials, and those with a high level of evidence such as controlled trials and meta-analyses. We used regression analysis to evaluate the effect of the year of publication on the number of publications of each type. SETTING: Not applicable. PARTICIPANTS: Not applicable. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Not applicable. RESULTS: MEDLINE reported a total of 98,501 adult publications and 30,895 pediatric publications during the evaluated period. There was a significant linear increase in the total number of publications in adult and pediatric rehabilitation publications with multiplication factors of 3.3 and 2.9, respectively. Importantly, publications with a high level of evidence showed larger multiplication factors compared with those with a low level of evidence (5.5 and 5.1 vs 2.1 and 2.0) for the adult and pediatric literature. CONCLUSIONS: The number of publications in the PMR field, especially those with a high level of scientific evidence, has increased linearly over the years, reflecting the rapid evolution of both adult and pediatric PMR.

The Effects of Acupuncture on Cerebral Blood Flow in Post-Stroke Patients: A Randomized Controlled Trial.

BACKGROUND/OBJECTIVE: Stroke is a major cause of disability and death in the Western world. Studies have shown a direct relationship between specific mental and motor activity and changes in cerebral blood flow. Acupuncture is often used in post-stroke patients, but there is a lack of sham-controlled studies evaluating the effects of acupuncture on cerebral blood flow following a stroke. This pilot concept-assessment study sought to evaluate the effects of true acupuncture on cerebral blood flow velocity compared with sham acupuncture and lay a foundation for future work in this field. METHODS: Seventeen inpatients (age range, 44-79 years) 1-3 months post-stroke were allocated to acupuncture at true acupuncture (TA) points or at sham acupuncture (SA) points. The treatment was 20 minutes long. Transcranial Doppler ultrasonography was used to measure mean flow velocity (MFV) and peak flow velocity (PFV) at both healthy and damaged hemispheres before (T0), in the middle of (T15), and 5 minutes after (T25) treatment. Blood pressure was measured at T0 and T25. RESULTS: A statistically significant (p < 0.04) MFV increase in both hemispheres was found during and after TA; this increase was higher than that seen with SA (p < 0.035). Acupuncture had no significant effect on PFV. Systolic blood pressure significantly decreased after acupuncture (p < 0.005) in a similar manner for both TA and SA. National Institutes of Health Stroke Scale score was negatively correlated with MFV at T15 (r = -0.825; p < 0.05). CONCLUSION: This pilot study showed a significant influence on cerebral blood flow velocity by TA. This study lays a foundation for larger-scale studies that may prove acupuncture to be a useful tool for cerebral blood flow enhancement during post-stroke rehabilitation.

Cognitive traits in inpatient adolescents with and without prior suicide attempts and non-suicidal self-injury.

OBJECTIVE: Establishing a psychiatric diagnosis and assessing suicidal tendencies is often a challenging task particularly in the early stages of an illness. Cognitive impairments characterize different psychiatric entities, but there is no known specific cognitive deficit profile that could help the clinician in achieving the diagnostic task. This study's aim was to establish a cognitive profile and test its ability to differentiate psychiatric inpatient subgroups, in terms of suicidal risk and diagnosis. The sample constituted of 76 consecutive admissions to the psychiatric adolescent day-care unit, who were admitted for any diagnosis. Assessment included full psychiatric interview and cognitive evaluation, using the COGNISTAT test. RESULTS: Of the 76 participants, 58% reported having suicidal ideation and 29% reported a prior attempted suicide. Subjects who had a prior suicide attempt had better orientation and attention scores in the COGNISTAT. Other cognitive domains did not differentiate between groups or diagnoses. CONCLUSION: These preliminary results suggest a significant association between specific cognitive characteristics and suicidal behavior in adolescents. Those cognitive characteristics might prove clinically useful in the assessment of suicide risk. Further study is needed to establish this association and generalize the conclusion to different populations.

A randomized controlled study of segmental neuromyotherapy for post-stroke hemiplegic shoulder pain.

OBJECTIVE: To assess the effectiveness of segmental neuromyotherapy combined with standard hospital therapy relative to standard therapy alone in patients with hemiplegic shoulder pain. DESIGN: Randomized controlled trial. PATIENTS: A total of 24 patients with positive Neer's and hand-behind-neck tests received standard therapy for shoulder pain. Half of them received additional segmental neuromyotherapy. METHODS: Pain severity (visual analogue scale), upper-limb function (Fugl-Meyer arm score), and spasticity (Ashworth scale) were evaluated at 2 days (T1) and 1 day (T2) pre-treatment, in the middle (T3) and at the end (T4) of 4 weeks treatment, and 2 months post-treatment (T5). RESULTS: The treatment group showed significant advantage compared with the Control group in Fugl-Meyer scores at T4 (p = 0.014) and T5 (p = 0.0078) compared with initial values. Significant advantage was also shown in the Neer's test at T4 (p = 0.014), with borderline significance at T5 (p = 0.072). A larger decrease in pain scores reported by the treatment group at T5 (p = 0.068) may have been biased by higher rates of spatial neglect in this group. CONCLUSION: Segmental neuromyotherapy added to standard therapy provides an advantage in pain relief and overall arm function in patients with hemiplegic shoulder pain.

Trigger point needling: techniques and outcome.

In this review we provide the updates on last years' advancements in basic science, imaging methods, efficacy, and safety of dry needling of myofascial trigger points (MTrPs). The latest studies confirmed that dry needling is an effective and safe method for the treatment of MTrPs when provided by adequately trained physicians or physical therapists. Recent basic studies have confirmed that at the site of an active MTrP there are elevated levels of inflammatory mediators, known to be associated with persistent pain states and myofascial tenderness and that this local milieu changes with the occurrence of local twitch response. Two new modalities, sonoelastography and magnetic resonance elastography, were recently introduced allowing noninvasive imaging of MTrPs. MTrP dry needling, at least partially, involves supraspinal pain control via midbrain periaqueductal gray matter activation. A recent study demonstrated that distal muscle needling reduces proximal pain by means of the diffuse noxious inhibitory control. Therefore, in a patient too sensitive to be needled in the area of the primary pain source, the treatment can be initiated with distal needling.

Underlying pathology and associated factors of hemiplegic shoulder pain.

The prevalence of hemiplegic shoulder pain is approximately 22%-23% in the general population of stroke survivors and approximately 54%-55% among stroke patients in rehabilitation settings. Hemiplegic shoulder pain causes a reduced quality-of-life, poor functional recovery, depression, disturbed sleep, and prolonged hospitalization. Herein, we attempted to understand, based on a literature review and experts' opinion, the pathologic processes underlying hemiplegic shoulder pain and the major associated factors contributing to its development. The systematization of underlying pathologies was proposed, which might eventually enable a more constructive clinical approach in evaluating and treating patients with hemiplegic shoulder pain.