Evidence-based position paper on Physical and Rehabilitation Medicine (PRM) professional practice on telerehabilitation. The European PRM position (UEMS PRM Section).

INTRODUCTION: The evidence on the utility and effectiveness of rehabilitation interventions delivered via telerehabilitation is growing rapidly. Telerehabilitation is expected to have a key role in rehabilitation in the future. AIM: The aim of this evidence-based position paper (EBPP) is to improve PRM physicians' professional practice in telerehabilitation to be delivered to improve functioning and to reduce activity limitations and/or participation restrictions in individuals with a variety of disabling health conditions. METHODS: To produce recommendations for PRM physicians on telerehabilitation, a systematic review of the literature and a consensus procedure by means of a Delphi process have been performed involving the delegates of all European countries represented in the UEMS PRM Section. RESULTS: The systematic literature review is reported together with the 32 recommendations resulting from the Delphi procedure. CONCLUSIONS: It is recommended that PRM physicians deliver rehabilitation services remotely, via digital means or using communication technologies to eligible individuals, whenever required and feasible in a variety of health conditions in favor of the patient and his/her family, based on evidence of effectiveness and in compliance with relevant regulations. This EBPP represents the official position of the European Union through the UEMS PRM Section and designates the professional role of PRM physicians in telerehabilitation.

Physical Rehabilitation of Motor Functional Neurological Disorders: A Narrative Review.

Functional Neurological Disorders (FNDs) are one of the most common and disabling neurological disorders, affecting approximately 10-30% of patients in neurology clinics. FNDs manifest as a range of motor, sensory, and cognitive symptoms that are not explained by organic disease. This narrative review aims to assess the current state of knowledge in physical-based rehabilitation for motor/movement FNDs in the adult population, with the goal of improving research and medical care for this patient population. To ensure optimal outcomes for patients, it is critical to consider several domains pertaining to FNDs, including which field of discipline they should belong to, how to investigate and test, methods for rating outcome measures, and optimal courses of treatment. In the past, FNDs were primarily treated with psychiatric and psychological interventions. However, recent literature supports the inclusion of physical rehabilitation in the treatment of FNDs. Specifically, physical-based approaches tailored to FNDs have shown promising results. This review utilized a comprehensive search of multiple databases and inclusion criteria to identify relevant studies.

Unilaterally Applied Resistance to Swing Leg Shows a Different Adaptation Pattern Compared to Split-Belt Treadmill in Patients with Stroke.

Persons with chronic stroke (PwCS) have a decreased ability to ambulate and walk independently. We aimed to investigate the differences between the motor adaptation process for two different perturbation methods: split-belt treadmill walking and unilaterally applied resistance to the swing leg during walking. Twenty-two PwCS undergo split-belt treadmill walking and unilaterally applied resistance to the swing leg during walking, each one week apart. The test included three phases: the baseline period, the early-adaptation period and the late-adaptation period, as well as the early-de-adaptation period and the late-de-adaptation period. The average step length, swing duration, double-limb support duration, and coefficient of variance (CV) of these parameters were measured. During the split-belt treadmill walking, PwCS showed an adaptation of double-limb support duration symmetry (p = 0.004), specifically a trend between baseline versus early-adaptation (p = 0.07) and an after-effect (late-adaptation compare to early-de-adaptation, p = 0.09). In unilaterally applied resistance to the swing leg during walking, PwCS showed lower swing phase duration CV, in the adaptation period (baseline compare to adaptation, p = 0.006), and a trend toward increased variability of gait in the de-adaptation period compare to the adaptation periods (p = 0.099). The rate of adaptation and de-adaptation were alike between the two perturbation methods. Our findings show that the learning process happening in the central nervous system of PwCS may be dependent on the nature of the perturbation (mechanical resistance vs. split-belt) and that PwCS are able to adapt to two types of errors.

Hospital-Based Rehabilitation of Patients Who Had Undergone an Open Reduction and Internal Fixation of the Ribs Due to a Flail Chest: Case Series.

Flail chest, a severe chest injury, is caused by multiple rib fractures. The open reduction and internal fixation (ORIF) of rib fractures is an effective treatment; however, the patients' subsequent condition remains unsatisfactory in terms of the activities of daily living (ADL) and pain. No research study has, as yet, reported on hospital-based rehabilitation of patients who had undergone an ORIF. Our aim was to evaluate the efficacy of hospital-based rehabilitation of flail chest post-ORIF patients. Physical therapists assessed the pain, functional independence measure (FIM), and the Berg balance test. A total of three females and four males (mean age 59.43 ± 18.88) were hospitalized. A significant reduction in pain was observed (7.00 ± 1.83 upon admission to 4.10 ± 2.05 pre-discharge (Z = -2.07, p = 0.027). A significant improvement in FIM (69.43 ± 14.86 upon admission to 113.57 ± 6.40 pre-discharge, Z = -2.37, p = 0.018), and the Berg balance test (35.23 ± 5.87 upon admission to 49.50 ± 3.40 pre-discharge, Z = -2.37, p = 0.018), was observed. Upon admission, all the patients required moderate to complete ADL assistance. Upon discharge, all were independent for all ADL functions. Patients after flail chest post-ORIF can benefit from hospital-based rehabilitation.

The Individual Rehabilitation Project as the core of person-centered rehabilitation: the Physical and Rehabilitation Medicine Section and Board of the European Union of Medical Specialists Framework for Rehabilitation in Europe.

To facilitate the interaction between the health professional and the patient, a framework to guide the rehabilitation process is needed. This framework would encompass three interwoven aspects: the rehabilitation management plan, Individual Rehabilitation Project (IRP), and rehabilitation cycle(s). All three framework aspects focus on the patient and on the aim of rehabilitation, i.e. to optimize a person's functioning across the continuum of care. An IRP is a multi-element, person-centered rehabilitation management scheme, in which rehabilitation is generally provided by a multiprofessional team under the leadership of a physical and rehabilitation medicine (PRM) physician, working in an interdisciplinary manner and together with the patient (or proxy). A reference system for operationalizing functioning and standardizing the process is the International Classification of Functioning, Disability and Health (ICF) - for assessing functioning needs, defining rehabilitation goals and outcomes. The objective of this paper is to present the IRP as a framework for rehabilitation in Europe (EUR-IRP). The specific aims are: 1) to introduce the IRP; and 2) to describe the framework components, elements and variables of the IRP. Demonstration projects (case studies) using the EUR-IRP will be conducted. The present paper presents the efforts to date for developing the EUR-IRP, a key part of the action plan of the PRM Section and Board of the European Union of Medical Specialists to implement the ICF systemwide across the care continuum. This paper serves as another step to bring together practice, science and governance in calling for contribution from rehabilitation clinicians and researchers and professional societies in PRM and beyond.

Ethical Issues in Medical Rehabilitation: The Dilemma of Who to Admit.

ABSTRACT: Ethical allocation of scare medical resources is a ubiquitous challenge in many, if not all, medical specialties. The field of physical medicine and rehabilitation is no exception and presents its own unique dilemmas. We report on a small inpatient rehabilitation unit at a large university medical center with a large catchment area representing a vast range of socioeconomic classes. The decision of whom to admit is a constant challenge. We review the existing literature regarding ethical considerations in rehabilitation department admission criteria and attempt to analyze criteria used to admit patients to a general physical medicine and rehabilitation ward. Finally, we discuss our medical center approach to the ethical dilemma of admission priority. A systemic search was conducted in six sources (PubMed, Google Scholar, ScienceDirect, Cochrane Library, LILACS, Embase). Searches were limited to English language articles with no date restriction, reflecting all available data. A reviewer applied the inclusion criteria to identify relevant articles.This review highlights a number of important ethical issues in evaluation and selection criteria that may assist clinicians in improving selection procedures and standardizing access to inpatient rehabilitation. Further high-quality empirical studies and reviews of ethical admission practice with regard to rehabilitation acceptance are required.

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.

Myofascial component of cancer pain review.

BACKGROUND: Pain is a common complaint of cancer patients, experienced by 38%-85% of patients. Some studies have shown a high incidence of myofascial pain syndrome (MPS) in cancer patients. AIMS: 1) To estimate the prevalence of MPS in cancer patients; 2) to examine the efficacy of current treatment options for MPS in cancer patients. METHODS: Narrative review. PubMed, CINAHL, PEDro, and Google Scholar databases were searched from inception until November 2017, for the keywords: cancer; cancer pain; breast cancer; mastectomy; lumpectomy; myofascial pain; trigger points. Trials of any methodological quality were included. All published material with an emphasis on randomized control trials was analyzed. RESULTS: MPS is prevalent in cancer patients who suffer from pain, with a prevalence of between 11.9% and 44.8% in those diagnosed either with neck or head or breast cancer. Clinical studies showed conflicting results. Four interventional studies found that specific treatment for MPS may reduce the prevalence of active myofascial trigger points and therefore decrease pain level, sensitivity, and improve range of motion (in shoulder) in cancer patients. Two recent randomized control trials showed that pressure release of trigger points provides no additional beneficial effects to a standard physical therapy program for upper limb pain and function after breast cancer surgery. CONCLUSIONS: We recommend including the evaluation of myofascial pain in routine clinical examination of cancer patients suffering from pain. Future studies are needed to investigate the long- and short-term effect of MPS treatments in cancer patients.

The impact of patient's weight on post-stroke rehabilitation.

Purpose To evaluate the influence of patient's weight on rehabilitation outcomes in first-event stroke patients. Design Retrospective, observational comparative study. 102 first-time stroke male and female patients admitted to the 52-bed neurology rehabilitation department in a rehabilitation hospital were included in the study. Body mass index (BMI), Functional Independence Measure (FIM) on admission and at discharge, as well as the delta-FIM (FIM on admission - FIM at discharge) were evaluated. The Kruskal-Wallis test was used to compare the FIM and the NIHSS scores between BMI groups (normal, overweight, moderate and severe obesity). Results A statistically significant negative correlation (rho = -0.20, p = 0.049) was found between FIM change and BMI, that remained significant after adjustments for age, sex and hospitalisation days. No difference was found between groups in FIM or NIHSS change between BMI groups. Conclusions In sub-acute post-stroke patients undergoing rehabilitation in rehabilitation hospital, BMI was negatively associated with the improvement of functional parameters. Patients' BMI should be taken into consideration when predicting rehabilitation outcome for stroke patients. Further investigations are needed to identify the functional parameters affected by the patients' BMI. Implications for Rehabilitation In sub-acute post-stroke patients undergoing rehabilitation in rehabilitation hospital, BMI was negatively associated with the improvement of functional parameters. Patients' BMI should be taken into consideration when predicting rehabilitation outcome for stroke patients. New rehabilitation strategies should be designed to improve the functional outcomes of rehabilitation of obese patients.

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.

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.

Muscle Strength, Function and Heart Autonomic Regulation System Recovery at the Sub-Acute Stage Post Stroke.

BACKGROUND: To compare the rate of recovery of motor and functional ability and heart rate variability (HRV) parameters during the inpatient rehabilitation period. SUMMARY: Twenty-three patients post first stroke at the sub-acute phase underwent motor and functional ability and HRV assessments 20 and 50 days after the event. A significant improvement was noted in motor and functional ability performance during the follow-up period, while no such change was noted in the HRV parameters. KEY MESSAGES: Patients post first-ever stroke exhibited a significant motor and functional improvement during the sub-acute phase post stroke, while no change was noted in their HRV parameters, which may imply that no significant changes in the sympatho-vagal balance took place during this period.

Rehabilitation versus Nursing Home Nurses' Low Back and Neck-Shoulder Complaints.

PURPOSE: To compare the prevalence of those complaints in nurses working in rehabilitation departments and nursing homes, and to evaluate factors associated with them. DESIGN: A cross-sectional study in rehabilitation and in nursing home departments. METHODS: Data were obtained from questionnaires relating to basic demographics, prevalence of musculoskeletal complaints, potentially harmful positions and actions and job satisfaction. FINDINGS: Multivariate analyses demonstrated higher work-related musculoskeletal complaints for nurses in rehabilitation than nursing home nurses (p=.012 for low back pain; p<.001 for neck-shoulder pain). Trunk bending, static posture, repetitive tasks, and recognition of superiors were associated with low back pain. Freedom to choose work techniques and degree of diversity at work were associated with neck-shoulder pain. CONCLUSIONS: Differences between the nurse groups as to work tasks might be a reason for differences in musculoskeletal complaints. Further comparisons between nurses working in different fields might reveal more accurate potential risk factors for work-related musculoskeletal complaints. CLINICAL RELEVANCE: Instruction for static/awkward posture avoidance, by using mechanical aids and designing a friendlier environment, should be part of a nursing staff injury prevention strategy.

Modified constraint-induced movement therapy improved upper limb function in subacute poststroke patients: a small-scale clinical trial.

BACKGROUND: Constraint-induced movement therapy (CIMT) has been advocated as a means of facilitating motor function in poststroke patients; however, the evidence for its efficacy is controversial. OBJECTIVE: To evaluate the effect of modified CIMT on improving paretic arm function in poststroke patients during a subacute rehabilitation period. METHODS: A single-blinded randomized controlled trial was conducted at the Loewenstein Rehabilitation Hospital, Israel. Twenty-eight subacute stroke patients with arm paresis after a first ischemic stroke in the middle cerebral artery area were randomized into a modified CIMT or control group by a 1:2 ratio. The modified CIMT group received 1-hour daily physical rehabilitation sessions for 2 weeks. The unaffected arm was restrained during the sessions. Subjects were encouraged to wear a restrictive mitten up to 4 hours a day. The control group received similar intensive regular rehabilitation. Three upper limb function tests, developed for this study, were used as outcome measures. The subjects were asked to perform the following tasks, with the affected hand for 30 seconds: (1) transfer pegs from a saucer to a pegboard; (2) grasp, carry, and release a hard rubber ball; and (3) "eating," using a spoon to remove the jelly from the plate, bring it towards the mouth, and then place it on another plate. The number of repetitions in each test was recorded as an outcome. RESULTS: The modified CIMT group showed significantly higher changes in all 3 tests compared to the standard rehabilitation group. CONCLUSION: Our study provides additional support for the use of modified CIMT during a subacute rehabilitation period of poststroke patients. CIMT may facilitate functional improvement of a plegic hand.

Constraint-induced movement therapy alters cerebral blood flow in subacute post-stroke patients.

We attempted to evaluate patterns of hemispheric activation, according to cerebral blood flow changes, in post-stroke patients during motor tasks with and without arm restriction. Bilateral continuous middle cerebral artery monitoring of 6 healthy subjects (control group) and 28 post-stroke patients by transcranial Doppler sonography was executed while performing three simple motor tasks using the paretic or nondominant (in controls) hand: ball grasping, pegs insertion, and "eating" with a spoon. The nonaffected or dominant (in controls) arm was free and thereafter restricted. Mean blood flow velocity and flow velocity changes during the tests were estimated. No significant mean blood flow velocity changes were found in the healthy subjects. Significant elevation of mean blood flow velocity in damaged middle cerebral artery was recorded in post-stroke patients after restricting the undamaged hand. This may explain the positive effect of constraint-induced movement therapy on upper limb function.

Age, gender and risk factor disparities in first-stroke Jewish and Arab patients in Israel undergoing rehabilitation.

BACKGROUND: Little is known of the risk factor disparities in first stroke among Jewish and Arab patients undergoing rehabilitation in Israel. OBJECTIVES: To investigate the age, gender and risk factor disparities in first stroke among Jewish (immigrant and non-immigrant) and Arab patients undergoing rehabilitation and to compare the prevalence and odds ratio of stroke risk factors in these patients. METHODS: The database of the Department of Neurological Rehabilitation C at Loewenstein Rehabilitation Center was used to investigate first ischemic and hemorrhagic stroke patients admitted for hospital rehabilitation over a 15 year period, January 1993 to December 2008. Particular attention was paid to age, gender and risk factor disparities. RESULTS: The 2000 patients with first stroke who were included in the study were grouped as Jewish (immigrant and non-immigrant) orArab; there were 237 Arabs, 370 non-immigrant Jews and 1393 immigrant Jews. A high percentage of Arab patients were found to have hypertension and diabetes mellitus, while a high percentage of Jewish immigrants had stenosis of the internal carotid artery. CONCLUSIONS: The study demonstrated some differences in the effect of risk factors between the groups. It may be important to address such differences when developing stroke preventative strategies in this population of Jewish and Arab stroke survivors in Israel.

Mean flow velocity in the middle cerebral artery is associated with rehabilitation success in ischemic stroke patients.

OBJECTIVE: To evaluate the association between mean flow velocity (MFV) in the middle cerebral artery (MCA) measured by using transcranial Doppler (TCD) and functional and neurologic impairment change during rehabilitation after acute stroke. DESIGN: Cross-sectional observational study. SETTING: Acute neurologic rehabilitation department. PARTICIPANTS: Consecutive patients (N=67; 53 men, 14 women; mean ± SD age, 61.54±8.92y) referred to the rehabilitation center during the first 6 months of 2006 for a first ischemic stroke in the MCA area. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: All subjects were evaluated on admission and at discharge by using the National Institutes of Health Stroke Scale (NIHSS) and the FIM. TCD measurements of MFV of the ipsilateral and contralateral MCA were performed on admission (during the first 20 days after stroke) and a few days before discharge. RESULTS: Contralateral MFV at admission was associated significantly with all indexes of functional rehabilitation success (FIM score at discharge [ß=.169; P=.010], change in FIM score [ß=.554; P=.010], relative improvement in FIM score [ß=.783; P=.003]). No significant association was found between indexes of NIHSS change and ipsilateral or contralateral MFV. CONCLUSIONS: Ipsilateral or contralateral MFV measured at admission did not change during the 2-month rehabilitation period. Our data showed a significant association between blood flow velocity in the contralateral MCA and functional rehabilitation parameters of patients after first ischemic stroke in the MCA area.