Management options of chronic low back pain. A randomized blinded clinical trial.

OBJECTIVE: To compare efficacies of 2 active programs in the management of chronic low back pain (CLBP). METHODS: This prospective, stratified, randomized single-blinded controlled study was conducted in the Department of Rehabilitation Medicine, King Abdullah University Hospital, Irbid, Jordan, between February and December 2010. A total of 100 patients were randomized to either 6-weeks of multidisciplinary rehabilitation (group A) or therapist-assisted exercise (group B). At baseline and 6 weeks, the visual analogue scale (VAS) pain score was estimated, as a primary outcome measure. McGill pain score, Oswestry Disability Index (ODI), trunk forward flexion and extension, left and right lateral bending, were applied before and after treatment and were employed as secondary outcome measures. RESULTS: All outcome measures significantly improved in group A after treatment, compared with group B. The VAS, McGill, ODI scores, left and right lateral bending decreased significantly, whereas forward and backward bending increased. A significant number of patients returned to work in group A at the end of 6 weeks, compared with group B. These effects were maintained over 12 and 24 weeks of follow-up. CONCLUSION: Multidisciplinary rehabilitation improved functional indices and pain scale scores in group A compared with B. This would be an effective strategy in CLBP management.

Effect of risk factors on functional outcome after stroke rehabilitation.

OBJECTIVE: The incidence of stroke and the demand for rehabilitation services continues to increase. Risk factors may act as stroke outcome predictors and hence determine the type and intensity of rehabilitation. Our aim is to investigate stroke outcome predictors that will define groups with maximal or minimal benefit from rehabilitation after stroke. METHODS: Our longitudinal prospective study included 111 ischemic stroke patients, admitted consecutively to the Rehabilitation Department, Hamad Medical Corporation, Qatar, during 2000-2001. We analyzed the influence of modifiable risk factors: diabetes mellitus (DM), hypertension (HTN), ischemic heart disease (IHD) and non-modifiable factors: age, gender, race and side of lesion on stroke outcome. All patients received regular rehabilitation and underwent an evaluation on admission and discharge, using the Modified Barthel Index. RESULTS: Statistical analysis demonstrated that the group of patients with IHD showed greatest improvement after 3 months of rehabilitation. The group without co-morbidities followed this, and then the HTN, DM, combined DM and HTN and combined HTN and IHD groups. The group that suffered from combined DM, HTN, and IHD did not show improvement. Non-modifiable risk factors showed no significant differences. However, younger patients showed a tendency for better improvement. CONCLUSION: Those patients with modifiable risk factors had significant impact on rehabilitation outcome (p-value = 0.009). Those with one or 2 co-morbidities had the highest score of improvement after rehabilitation while the group of patients with more than 2 co-morbidities did not show improvement. However, non-modifiable risk factors did not play a significant role in stroke outcome.

Homocystinemia and stroke in vegetarians.

Homocysteine is a sulfurated amino acid with a central role in the metabolism of thiol compounds. Homocystinemia is a recognized independent potentially remediable risk factor for vascular disease. It is associated with both macro and micro vascular ischemic stroke. It can often be normalized by polyvitamin therapy. This inexpensive and well-tolerated treatment is considered effective in decreasing the incidence of stroke. We report 2 young strict vegetarians with no known vascular risk factors. The first suffered a left middle cerebral artery infarct, and the second multiple bilateral small cerebral infarctions. Extensive investigations showed moderately elevated homocysteine and low serum B12 levels, suggesting that these are most probably the underlying etiology. We believe that a high index of suspicion is needed, particularly in younger people with a potential underlying cause for B12 deficiency and no identifiable stroke risk factor.

Autonomy and rehabilitation.

In minority world countries, autonomy is central to client focused rehabilitation, as it represents a prerequisite for effective participation in the process of rehabilitation. The diverse and dynamic paradoxes within the "autonomy paradigm" will ensure its safe application and survival in such communities. However, the strong family relationships and different cultural backgrounds of majority world countries motivate us to conclude that a "patient-family interactive deliberative process" based on accommodation and negotiation is more acceptable, reliable and implementable in these communities. Our suggested model of decision making is more convenient, particularly in cases where competency is compromised by cognitive dysfunction, political or religious restrictions. The insistence on absolute autonomy beyond such borders could be counter productive for both patients and health care personnel. Clearly, the need for further research is paramount, as a deeper understanding of the various cultures and subcultures is essential for developing a more useful structural framework for rehabilitation.