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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Impairment, disability, and life satisfaction in Parkinson's disease.

PURPOSE: To determine the correlation of motor and musculoskeletal impairments with disability scores and life satisfaction. Musculoskeletal impairments might be due to the impact of motor impairments, however some cases may have these impairments even before the disease is diagnosed. METHODS: 48 consecutive patients (32 male, 16 female) with Parkinson's disease with a mean age of 65.6, mean age of onset of the disease of 59.8, and Hoehn and Yahr staging system 1-4 participated. Unified Parkinson's disease rating scale, modified Schwab and England activities of daily living scale and life satisfaction index were used. Also New York modified mobility rating scale for c-spine and upper extremities and trunk and lower extremities was performed. RESULTS: Motor and musculoskeletal impairments were correlated with the disability score. Bradykinesia, and tremor were correlated with upper and lower extremity range of motion limitation, but rigidity was not. Bradykinesia was correlated with life satisfication. Having had the disease longer was related to upper extremity range of motion limitation. CONCLUSIONS: Motor and musculoskeletal impairments are correlated with disability scores. Bradykinesia and musculoskeletal impairments are correlated with life satisfication. Patients with Parkinson's disease might benefit from a rehabilitation programme focusing on motor impairments such as bradykinesia as well as musculoskeletal impairments even in the early stages of the disease.

Validation of the Turkish version of the Roland-Morris Disability Questionnaire for use in low back pain.

STUDY DESIGN: A reliability and validity study of a previously translated version of the Roland-Morris Disability Questionnaire (RMDQ). OBJECTIVES: To validate the Turkish version of the RMDQ for use in low back pain. SUMMARY OF BACKGROUND DATA: Clinical and epidemiologic research related to low back pain in the Turkish population would be facilitated by the availability of well-established outcome measures. METHODS: A total of 81 outpatients with low back pain, 64 of whom were followed up on a second occasion, were assessed by the RMDQ. Reliability was assessed using internal consistency and the intraclass correlation coefficient. Internal construct validity was assessed by Rasch analysis; external construct validity was assessed by association with pain and spinal movement. Responsiveness was tested by both the nonparametric and parametric effect sizes. RESULTS: Internal consistency of the RMDQ is found to be adequate (>0.85) at both times, with high intraclass correlation coefficient also at both time points. Internal construct validity of the scale is good, indicating a single underlying construct. Expected associations with pain confirm external construct validity. There is little evidence of differential item functioning. The scale is at the ordinal level. Responsiveness of the RMDQ is good and greater than observed change in spinal movement. CONCLUSIONS: The RMDQ is a robust unidimensional ordinal measure, largely free of differential item functioning, which works well in the Turkish population. Nonparametric effect sizes of ordinal scales are found to overestimate or underestimate the true effect size depending on the nature of the scale and the distribution of patients at baseline.

Adaptation of the Functional Independence Measure for use in Turkey.

OBJECTIVE: To adapt the Functional Independence Measure (FIM) for use in Turkey and to assess its validity and reliability. DESIGN: After the translation procedure, reliability was assessed using internal consistency, inter-rater reliability (kappa) and the intraclass correlation coefficient (ICC). Construct validity was tested by association with impairments and by fit of data to the Rasch model. SETTING: The study was undertaken in an inpatient rehabilitation unit of the Department of Physical Medicine and Rehabilitation, Faculty of Medicine, University of Ankara. SUBJECTS: Consecutive stroke (n = 51) and spinal cord injury (SCI) (n = 62) patients admitted for rehabilitation over a period of three years were assessed at admission and discharge. RESULTS: Internal consistency was good for stroke, and for SCI. The level of agreement between two raters was sufficient with kappa levels of above 0.48 for SCI and above 0.44 for stroke. Minimum ICC found was 0.90. Construct validity showed expected associations with the impairment scales. However, Rasch analysis showed that bladder and bowel items compromise unidimensionality in the motor scale. CONCLUSION: Adaptation of the FIM has been successful and it can be used in Turkey as long as the limitations are recognized.

Rehabilitation of stroke patients: clinical profile and functional outcome.

OBJECTIVE: To describe the nature of functional recovery of 67 Turkish survivors of first-episode stroke who were referred for inpatient rehabilitation and to identify the variables that best predict discharge functional status of these patients. DESIGN: A retrospective, descriptive study of the demographic and clinical profile and the functional status of patients with first-episode stroke. RESULTS: The mean age was 60 (11.8, SD) yr, and 35.8% were men. The mean onset-admission interval and length of stay were 62.9 and 97.1 days, respectively. The mean functional status score, as measured by the FIM instrument, at the time of admission was 75 compared with 86.7 at the time of discharge, showing a mean improvement of 11.7. Although rehabilitation gains were similar for the right- and left-side involved groups, patients with right-side paresis had lower FIM scores at the time of admission than did the left-side involved group. Significant predictors of functional status at the time of discharge were admission functional status score and onset-admission interval. CONCLUSION: Knowledge of these predictors can contribute to more appropriate treatment and discharge planning.

Adaptation of the modified Barthel Index for use in physical medicine and rehabilitation in Turkey.

The aim of this study was to adapt the modified Barthel Index for Turkey and to determine its reliability and validity. After the translation procedure, 50 stroke patients and 50 spinal cord injury patients, undergoing inpatient rehabilitation were assessed by the newly adapted index at admission and discharge. Reliability was tested using internal consistency, inter-rater reliability and the intra-class correlation coefficient. Construct validity was assessed by association with impairments (Brunnstrom motor stages in stroke, American Spinal Injury Association motor/sensory scores and impairment scale in spinal cord injury) and by Rasch analysis. Internal consistency was good at 0.93 for stroke, and 0.88 for spinal cord injury. The level of agreement between two raters was sufficient with Kappa levels of above 0.5 for spinal cord injury and above 0.6 for stroke. Intra-class correlation coefficients were 0.99 and 0.77 for stroke and spinal cord injury, respectively. The newly adapted index showed expected associations with the impairment scales, confirming its construct validity. However, Rasch analysis showed that bladder and bowel items compromise unidimensionality. In conclusion, adaptation of the modified Barthel Index has been successful and it can be used in Turkey as long as its limitations are recognized.

The development and psychometric assessment of the Turkish version of the Nottingham Health Profile.

The Nottingham Health Profile (NHP) is a widely used measure of perceived health status. The aim of the present study was to adapt the NHP for use in Turkey and to test its psychometric properties. Following translation and testing for its face and content validity, 50 patients with osteoarthritis were interviewed on two occasions. Each interview included administration of the NHP and the Stanford Health Assessment Questionnaire (HAQ), a measure of functional disability. Test-retest reliability of the new version was satisfactory and comparable with other available language versions. As predicted, high correlations were found between the HAQ and the physical mobility, pain and energy level sections of the NHP and low correlations between the HAQ and emotional reactions, social isolation and sleep, confirming the construct validity of the NHP. It is concluded that the adaptation of the NHP into Turkish was successful but that additional studies are required to assess its suitability for use with other patient populations and its equivalence to other language versions of the measure.