Combining balneotherapy and health promotion to promote active and healthy ageing: the Balaruc-MACVIA-LR® approach.

Scaling up and replication of successful innovative integrated care models for chronic diseases is one of the targets of the European Innovation Partnership on Active and Healthy Ageing (EIP on AHA). MACVIA-LR® (MAladies Chroniques pour un VIeillissement Actif en Languedoc-Roussillon) is a Reference Site of the EIP on AHA. The main objective of MACVIA-LR® is to develop innovative solutions in order to (1) improve the care of patients affected by chronic diseases, (2) reduce avoidable hospitalization and (3) scale up the innovation to regions of Europe. The MACVIA-LR® project also aims to assess all possible aspects of medicine-including non-pharmacologic approaches-in order to maintain health and prevent chronic diseases. These approaches include hydrotherapy and balneotherapy which can be of great importance if health promotion strategies are considered. Balneotherapy at Balaruc-les-Bains focusses on musculoskeletal diseases and chronic venous insufficiency of the lower limbs. Each year, over 46,000 people attend an 18-day course related to a new falls prevention initiative combining balneotherapy and education. On arrival, each person receives a flyer providing information on the risk of fall and, depending on this risk, a course is proposed combining education and physical activity. A pilot study assesses the impact of the course 6 and 12 months later. This health promotion strategy for active and healthy ageing follows the FEMTEC (World Federation of Hydrotherapy and Climatotherapy) concept.

Which physical activities and sports can be recommended to chronic low back pain patients after rehabilitation?

BACKGROUND: Physical exercise is widely prescribed in rehabilitation programmes for low back pain (LBP). The LBP patient often asks whether this physical activity should be maintained and, in some cases, whether he/she should resume or take up a sport. PURPOSE: To answer these two questions by performing a review of literature on the efficacy and safety of post-rehabilitation physical activities and sport in LBP. METHOD: A systematic search of computerized databases from 1990 to 2011 was performed using grade 1 to 4 studies articles in English or French. RESULTS: Of the 2583 initially identified articles, 121 articles were analysed. Globally, physical activities like swimming, walking and cycling, practiced at moderate-intensity help to maintain fitness and control pain. Inconsistent results were found for avoiding recommendations according to the nature of PA. Sport activities, except ballgames, can be easily resume or take up as tennis, horse riding, martial arts, gymnastics, golf and running which can be performed at a lower intensity or lower competitive level. DISCUSSION AND CONCLUSION: Moderate but regular physical activity helps to improve fitness and does not increase the risk of acute pain in chronic LBP patients. The resumption of a sport may require a number of adaptations; dialogue between the therapist and the sports trainer is therefore recommended.

Evaluation of various ways to deliver information concerning non-steroidal anti-inflammatory drugs to osteoarthritis patients.

INTRODUCTION: It is essential to provide complete information to patients using non-steroidal anti-inflammatory drugs (NSAIDs) because of the risk of side effects. Today, most healthcare professionals recommend and privilege oral information regarding NSAIDs. OBJECTIVE: Evaluate the impact of three standardized NSAIDs information-delivery modalities on knowledge, anxiety and satisfaction of patients hospitalized in a Physical Medicine and Rehabilitation unit for debilitating and degenerative locomotor diseases. METHOD: Randomized prospective study with an alternate month design. Two control groups were provided with only one type of information modality: written (information sheet) or oral (presentation). The intervention group received both modalities of information. The information included: the definition of NSAIDs, advantages and side effects, and practical advice regarding proper use. The main evaluation criterion was knowledge progression assessed by a specific questionnaire. Secondary criteria were anxiety evolution (STAI-Y questionnaire) and satisfaction related to the information delivered. RESULTS: One hundred and forty patients were included. Knowledge was improved in the three groups, with a greater score improvement in the group that received both modalities (P=0.05). No intergroup difference was noted on anxiety or satisfaction. DISCUSSION AND CONCLUSION: Associating both information-delivery modalities (written+oral) contributes to improving knowledge but does not seem to have an impact on the anxiety of patients treated with NSAIDs for their degenerative locomotor disease. Using standardized information sheets with a validated content could help pharmacists in their role as healthcare education provider and effectively complement the information delivered orally.

Isokinetic muscle strengthening after acquired cerebral damage: a literature review.

OBJECTIVE: Isokinetic strengthening is a rehabilitation technique rarely used in stroke patients. However, the potential benefits of force and endurance training in this population are strongly suspected. METHOD: This literature review synthesizes the results of clinical trials on this topic. The research was conducted on PubMed, using "Stroke", "rehabilitation", "isokinetic", "upper limb" and "training" as keywords. RESULTS: Seventeen studies focusing on the use of isokinetics in assessment or rehabilitation (six studies) following stroke were reviewed. For the lower limb, muscle strength and walking ability improved after isokinetic rehabilitation programs. For the upper limb, the only two studies found in the literature suggest improvement in the strength of the trained muscles, of grip force, of the Fugl-Meyer motor score and of global functional capacities. This review does not reveal any consensus on the protocols to be implemented: type of muscle contraction, velocities…. CONCLUSION: While isokinetic strengthening has not proven its efficiency in rehabilitation of the upper limb following stroke, its interest with regard to rehabilitation of the lower limbs has been recognized. Randomized controlled trials in this field are necessary to confirm its efficiency, especially concerning upper arm rehabilitation.

Education in the management of low back pain: literature review and recall of key recommendations for practice.

INTRODUCTION: Therapeutic patient education (TPE) is a continuous medical care process whose role in lower back pain (LBP) has yet to be well defined. OBJECTIVE: To evaluate the role and impact of TPE in the medical and surgical management of LBP. METHOD: A non-systematic literature review. RESULTS: Few formal TPE programmes have been rigorously evaluated in the context of LBP. In most cases, TPE tools have been combined with other interventional measures that vary according to the conceptual models used - thus limiting the extent to which the effect of TPE alone can be judged. Information that complies with the guidelines modifies knowledge and inappropriate beliefs. Whether formalized or not, TPE appears to modify (i) the physical disability and pain related to LBP and (ii) the patient's choice of therapy (e.g. surgery). The impact appears to be more marked in the (sub)acute phases. DISCUSSION: National and international guidelines suggest that TPE based on a biopsychosocial model has a positive impact on the patients' behaviour and treatment compliance. The cost/benefit ratio appears to be favourable. CONCLUSION: Therapeutic patient education appears to reduce the negative consequences of fear-avoidance behaviour and thus promotes treatment compliance in LBP patients, from the acute phase onwards.

Reproducibility of isokinetic peak torque assessments of the hip flexor and extensor muscles.

OBJECTIVES: Isokinetic assessment is currently the reference method for measuring dynamic muscle strength. We have sought to evaluate the reproducibility over time of isokinetic testing of the hip flexor (FI) and extensor (Ext) muscles and to establish whether there is a significant difference in peak torque (PT) between the left and right hips. PATIENTS AND METHODS: Ten adults were tested once a week for 3 weeks by the same investigator and according to the same protocol, with two velocities (60 degrees /s and 180 degrees /s) for the hip FI and Ext in concentric tests and one velocity (30 degrees /s) for the Ext only in eccentric tests. The reproducibility of the measured PT was analyzed by using the intraclass correlation coefficient (ICC) and a Bland and Altman plot. The difference in PT between the right and left hips was tested using Student's T test. RESULTS: The ICC for the observed PT values revealed very good reproducibility (with a value of between 0.75 and 0.96) for the hip FI and Ext measurements (regardless of the body side, test velocity or contraction mode). We did not observe any significant PT differences between the right and left hips. CONCLUSION: The isokinetic assessment of the concentric and eccentric PT values generated by the hip FI and Ext is highly reproducible. There is no difference between dominant and nondominant body sides, which enables the use of the contralateral limb as a reference.

Aging and sequelae of poliomyelitis.

OBJECTIVE: We estimate that there are about 50,000 persons who survived poliomyelitis in their childhood in France (mean age estimated between 50 and 65 years). After a few decades of stability, 30 to 65% of individuals who had been infected and recovered from polio begin to experience new signs and symptoms. METHOD: Review of the literature on Pubmed with the following keywords "Poliomyelitis" and "Post-Polio Syndrome (PPS)". RESULTS: These new signs and symptoms are characterized by muscular atrophy (decreased muscle mass), muscle weakness and fatigue, muscle and/or joint pain. All these symptoms lead to significant changes in mobility with falls and inability to carry on with daily life activities. There are several intricate causes. The normal aging process and weight gain are regularly blamed. Respiratory disorders and sleep disorders must be looked for: respiratory insufficiency, sleep-related breathing disorders such as sleep apnea, restless legs syndrome. Orthopedics complications are quite common: soft-tissue pathologies of the upper limbs, degenerative pathologies of the large joints or spinal cord, fall-related fractures. Finally, the onset of an authentic PPS is possible. CONCLUSION: The therapeutic care of this late functional deterioration requires regular monitoring check-ups in order to implement preventive measures and appropriate treatment. This therapeutic care must be multidisciplinary as physical rehabilitation; orthotics and technical aids are all essential.

The importance of fear, beliefs, catastrophizing and kinesiophobia in chronic low back pain rehabilitation.

AIM: To evaluate fear, beliefs, catastrophizing and kinesiophobia in chronic low back pain patients about to begin a training programme in a rehabilitation centre. PATIENTS AND METHODS: Fifty chronic low back pain patients (including both males and females) were assessed in our physical medicine department. We used validated French-language scales to score the patients' pain-related disability, quality of life and psychosocial factors. RESULTS: Seventy percent of the patients had a major functional disability (i.e., a Roland-Morris Scale score over 12) and nearly 73% reported an altered quality of life (the daily living score in the Dallas Pain Questionnaire). Pain correlated with functional impairment and depression but not with catastrophizing or kinesiophobia. Disability was correlated with catastrophizing and kinesiophobia. CONCLUSION: Psychosocial factors are strongly associated with disability and altered quality of life in chronic low back pain patients. Future rehabilitation programs could optimizing patient management by taking these factors into account.

Osteoporotic fracture of the sacrum: sacroplasty and physical medecine.

CONTEXT: Traditional treatment of sacrum osteoporotic fractures is mainly based on antalgics and rest in bed. But complications are frequent, cutaneous, respiratory, thrombotic or digestive and mortality at 1 year significant. THE AIMS: We wanted to define the interest of sacroplasty when treating osteoporotic fracture of sacrum. METHOD: We reviewed literature while studying a clinical case in an elderly patient. RESULTS: Sacroplasty was efficient at short and mean delay to control the pain due to osteoporotic sacrum fracture. Rate of complications is low in the centers mastering the procedure. CONCLUSION: Sacroplasty is of evident interest for elderly patients suffering of an osteoporotic fracture of sacrum. It reduces decubitus complications, secondary effects of antalgics and allows an early reeducation.

The effect of music therapy on mood and anxiety-depression: an observational study in institutionalised patients with traumatic brain injury.

INTRODUCTION: A previous study (carried out in 2003-2004) had included 34 patients with traumatic brain injury in order to study the feasibility and usefulness of music therapy in patients with this type of injury. OBJECTIVE: To evaluate the effect of music therapy on mood, anxiety and depression in institutionalised patients with traumatic brain injury. STUDY METHODOLOGY: A prospective, observational study. MATERIALS AND METHODS: Thirteen patients with traumatic brain injury were included in the present study and took part in individual, weekly, 1-hour music therapy sessions over a period of 20 weeks. Each session was divided into two 30-minute periods - one devoted to listening to music (receptive music therapy) and the other to playing an instrument (active music therapy). The assessment criteria (measured at weeks 1, 5, 10, 15 and 20) were mood (on the face scale) and anxiety-depression (on the Hospital Anxiety and Depression [HAD] Scale). Mood was assessed immediately before and after the first music therapy session and every fifth session. RESULTS: Music therapy enabled a significant improvement in mood, from the first session onwards. This short-term effect was confirmed by the immediate changes in the scores after music therapy sessions (from 4.6+/-3.2 to 2.6+/-2; p<0.01). Music therapy also led to a significant reduction in anxiety-depression (p<0.05) from week 10 onwards and up until the end of the study (week 20). CONCLUSION: These results confirm the usefulness of music therapy in the treatment of anxiety-depression and mood in patients with traumatic brain injury. Music therapy could usefully form an integral part of the management programme for these patients.

Qualitative evaluation of the expectations of low back pain patients with regard to information gained through semi-directed navigation on the Internet.

OBJECTIVES: To make a qualitative analysis of the expectations of chronic low back pain (LBP) sufferers with regard to information gained using semi-directed Internet navigation on a sample of French LBP-related websites, and to compare the results with those of physical medicine and rehabilitation (PMR) medical doctors (MD). MATERIAL AND METHODS: Twenty-seven hospitalised chronic LBP sufferers assessed in ecological conditions a sample of seven LBP-related websites. The sites were assessed using a simplified version of a rating scale of patients' expectations. Analysis of the relative importance of the different kinds of information delivered was done using a point sharing method. RESULTS: In a comfortable environment, patients gave high scores for medical and extra-medical information, but low scores for website design. Overall quality assessment was similar for patients and MDs. The relative importance of medical and extra-medical information, and design quality, was similar for Chronic LBP patients and MDs. CONCLUSION: PMR MD seemed able to correctly evaluate the overall expectations of chronic LBP patients with regard to information, but their opinions on the different qualities of websites were different. Doctors and patients should collaborate in order to create or validate high quality websites concerned with LBP.

[Complex regional pain syndrome of the knee: early and beneficial action of diphosphonates on pain and function]. / Algodystrophie de genou: effet précoce et spectaculaire des biphosphonates sur la douleur et la fonction.

We report the case of a 24-years-old man with parcellar Complex Regional Pain Syndrome I (CRPS I) of the patella, responsible for major functional limitation. The diagnosis was based on physical exam and X-ray, in the absence of other articular or peri-articular diseases. The patient received two pamidronate perfusions over a week, with a spectacular decrease of pain, which allowed him to follow the rehabilitation program in good conditions. He was therefore able to go back to work. The place of this treatment in CRPS I is discussed.

[Does the quality of Web sites related to low back pain meet patients expectations? A systematic review]. / La qualité de l'information disponible sur Internet concernant la lombalgie est-elle adaptée aux attentes des patients? Revue systématique.

INTRODUCTION: An assessment of 36 back-pain-related French-language Web sites, miming a patient search strategy, was previously done by use of evidence-based items. Medical information quality was poor, as already noted about English-language Web sites. Thus, patients' expectations may exceed that provided by Web sites with simple medical information. OBJECTIVES: To study whether French-language Web sites related to low back pain meet patients expectations and to valid a rating scale including patients' expectations. MATERIALS AND METHOD: First we reviewed French-language Web sites with new keywords and medical gateways. Second, we systematically double assessed back pain-related Web sites with a health care professional and patient-centered scale. RESULTS: We found 30 additional Web sites not found with the previous search, 7 focusing on patient information. The rating scale is valid, and its use on a Web site sample leads to results different from those generated by an evidence-based medicine rating scale but close to a more global assessment. DISCUSSION: French-language Web sites related to low back pain do not meet patients' expectations. Patients participation in Web site assessment or construction could help to close the gap between the expectations of people with low back pain and information delivered by doctors.

[The role of an information booklet or oral information about back pain in reducing disability and fear-avoidance beliefs among patients with subacute and chronic low back pain. A randomized controlled trial in a rehabilitation unit]. / Un simple livret d'information peut contribuer à réduire l'incapacité fonctionnelle de patients lombalgiques subaigus et chroniques. Etude contrôlée randomisée en milieu de rééducation.

OBJECTIVES: To compare the efficacy of an information booklet or oral information about back pain in reducing disability and fear-avoidance beliefs among patients with subacute and chronic low back pain referred to a rehabilitation department. METHODS: An alternate-month design was used for 142 patients with subacute or chronic low back pain who were hospitalized for treatment. Seventy-two patients received written standardized information about back pain (the "back book") and usual physical therapy (intervention group), and 70 received usual physical therapy only along with nonstandardized oral information (control group). The main outcome measure was disability (measured on the Quebec back-pain disability scale), and secondary outcome measures were pain intensity (measured on a visual analog scale), fear-avoidance beliefs (measured on the Fear-Avoidance Beliefs Questionnaire [FABQ] Physical component), and knowledge of the relation of back pain to physical activity assessed at baseline, just before discharge from the hospital and 3 months after discharge. Satisfaction related to the information received was assessed on the day of discharge. RESULTS: Receiving the "back book" had a significant impact on disability at 3 months, from 48.40+/-14.55 to 34.57+/-18.42 in the intervention group and from 52.17+/-16.88 to 42.40+/-14.95 in the control group (p=0.03). Receipt of the book also had a significant impact on patients' knowledge and satisfaction about information but a nonsignificant effect on fear-avoidance beliefs. CONCLUSIONS: Providing an information booklet about back pain to patients with subacute and chronic low back pain referred to a rehabilitation unit contributes to reduced disability in these patients.

[Feet insoles and knee osteoarthritis: evaluation of biomechanical and clinical effects from a literature review]. / Orthèses plantaires et gonarthrose: évaluation des effets biomécaniques et cliniques à partir d'une revue de la littérature.

OBJECTIVE: To determine the biomechanical and clinical effectiveness of foot insoles in patients with knee osteoarthritis. MATERIALS AND METHODS: A systematic review of the literature (Medline, Pascal and Embase) using the MESH words knee, and insole and plantar orthosis for the biomechanical part and osteoarthritis, and insole and plantar orthosis for the clinical part. Clinical studies were classified by 2 independent readers using the Jadad scale. RESULTS: Two biomechanical theories were found: the adduction moment theory, which explains the effect of heel wedging, and articular chain theory, which explains the effect of lateral wedged insoles. The clinical effect was explained more by an anti-algesic effect than an anatomic or functional effect: the treated group consumed fewer nonsteroidal anti-inflammatory drugs than the placebo group for up to 2-years of treatment. Evidence is lacking because of methodological weakness and few clinical trials. The information on side effects is limited. DISCUSSION: Laterally wedged foot insoles are proposed for the treatment of knee medial compartment osteoarthritis. The clinical effect is probably limited, but the treatment may reduce the digestive and renal side effects of prolonged use of nonsteroidal anti-inflammatory drugs. Foot insoles could be recommended in clinical practice despite the lack of evidence in comparing the effectiveness of other therapeutics in knee osteoarthritis. CONCLUSION: Use of foot insoles is a nonpharmacologic treatment of osteoarthritis of the knee medial compartment.

[C-reactive protein, leukocyte count and D-dimer monitoring after orthopedic surgery: early diagnosis of infectious or thromboembolic complications. Part two: does d-dimer measurement contribute to the diagnosis of postoperative venous thromboembolism?]. / Surveillance biologique après chirurgie orthopédique. Quel apport au diagnostic des complications infectieuses et thromboemboliques? Deuxième partie: le dosage des D-dimères a-t-il un intérêt dans le diagnostic des accidents thromboemboliques postopératoires?

OBJECTIVES: To determine the modification in postoperative D-dimer level as a function of the surgical act and to assess the relevance of this measure for diagnosing thromboembolism. METHOD: A cohort of 179 patients was followed: group 1 comprised 128 patients undergoing lower limb arthroplasty, group 2 comprised 29 patients undergoing lower limb surgery without implant, and group 3 comprised 22 patients undergoing spinal or upper limb surgery. D-dimer level was systematically measured on admission and then once a week for 4 weeks. Doppler ultrasonography was performed on clinical suspicion of deep vein thrombosis. D-dimer levels were compared between patients with and without deep vein thrombosis. RESULTS: D-dimer levels were constantly elevated postsurgery (2- to 6-fold above normal) and returned to normal by week 4 in groups 2 and 3 but remained elevated in group 1 (3-fold above normal). Deep vein thrombosis was suspected in 45 cases and confirmed by Doppler ultrasonography in 10 cases. D-dimer level was not significantly different between patients with deep vein thrombosis and those without. DISCUSSION AND CONCLUSIONS: In the postoperative period, measurement of D-dimer level does not aid in diagnosing thromboembolism since its constant high level obviates any negative predictive value.

[C-reactive protein, leukocyte count and D-dimer monitoring after orthopedic surgery: early diagnosis of infectious or thromboembolic complications. Part one: C-reactive protein and leukocyte count as an aid in diagnosing postoperative infection]. / Surveillance biologique après chirurgie orthopédique. Quel apport au diagnostic des complications infectieuses et thromboemboliques? Première partie: évolution de la CRP et des leucocytes. Place dans la strategie diagnostique des infections postopératoires.

OBJECTIVES: To evaluate the usefulness of monitoring C-reactive protein (CRP) level and leukocyte count for early diagnosis of infection following orthopedic surgery. METHOD: A cohort of 179 patients was followed: group 1 comprised 128 patients undergoing lower limb arthroplasty, group 2 comprised 29 patients undergoing lower limb surgery without implant, and group 3 comprised 22 patients undergoing spinal or upper limb surgery. CRP level and leukocyte count were systematically measured on admission and then once a week for 4 weeks. Wound infections, other infections, wound disconnection without infection and hematoma were noted. CRP level and leukocyte count were monitored postoperatively in patients with and without complications. RESULTS: CRP level was 4- to 8-fold above the normal range at the first postoperative measurement but normalized within the next 3 weeks (reaching normal levels by the 30th postoperative day, on average). In the 7 cases of wound infection (WI), the CRP level rose to 28-fold above normal and was significantly different from that in without infection or with intercurrent infection (P<0.01). A receiver operating characteristic (ROC) curve was established for CRP level, and for a value of 60 (12-fold above the normal range) the sensitivity was 100%, the specificity 83.6% and the negative predictive value 100%. The variation in leukocyte count was minor, with a significant difference noted between only patients not infected or those with WI (P<0.05). DISCUSSION AND CONCLUSIONS: Measurement of CRP level can be used for early diagnosis of wound infection. In the case of strong clinical suspicion or in the presence of high risk factors, when the level is at 12-fold or more above the normal range, the diagnosis of infection is highly probable.

[Effect of music therapy among hospitalized patients with chronic low back pain: a controlled, randomized trial]. / Intérêt de la musicothérapie dans la prise en charge de la lombalgie chronique en milieu hospitalier (Etude contrôlée, randomisée sur 65 patients).

OBJECTIVE: To evaluate the influence of music therapy in hospitalized patients with chronic low back pain. METHODS: A controlled, randomized study (N = 65). During a stationary rehabilitation stay of 12 days, 65 patients with low back pain were randomized to receive on alternate months standardized physical therapy plus 4 music therapy sessions between day 1 and day 5 (intervention group; N = 33) or standardized physical therapy alone (control group; N =32). Scores for pain (as measured on a visual analogue scale [VAS]), disability (Oswestry index) and anxiety and depression (as measured on the hospital anxiety and depression scale [HAD]) were collected on day 1, 5 and 12. Pain intensity was also evaluated on a VAS just before and after music therapy sessions. RESULTS: Introduced music therapy sessions during a stationary rehabilitation stay in patients with chronic low back pain reduce pain (-2.0+/-2.7 vs -1.8+/-2.6) but not significantly. However, music therapy significantly (p < 0.01) reduced disability as measured on the Owestry index between day 1 and day 5 (-11.8+/-17.8 vs -2.5+/-9.4), anxiety (-3.5+/-3.7 vs -0.9+/-2.7) and depression (-2.1+/-3.0 vs 0.6+/-2.4). The immediate effect on pain intensity (VAS score) was confirmed (p < 0.001). CONCLUSION: Our results confirmed the effectiveness of music therapy for hospitalized patients with chronic low back pain. Music therapy can be a useful complementary treatment in chronic pain and associated anxiety-depression and behavioural consequences.