Clinical efficacy of scalp electroacupuncture combined with rehabilitation training for aphasia after head injury and its effect on patients' language function and quality of life: An observational study.

To explore the clinical efficacy of scalp electroacupuncture combined with rehabilitation training for aphasia after head injury, and analyze its effect on patients' language function and quality of life. Our hospital randomly enrolled 100 aphasia patients caused by head injury treated from March 2020 to March 2022 as the experimental object and divided them into the control group and experimental group, with 50 cases in each group. The general rehabilitation training was performed to the control group and the scalp electroacupuncture combined with rehabilitation training was performed to the experimental group to compare their mini-mental state examination scores, communicative activities in daily living scores, aphasia battery of Chinese scores, quality of life scores, mental status scale in nonpsychiatric settings scores, National Institutes of Health Stroke Scale scores, effective rates, satisfaction of patients, and adverse reaction rates. In the between-group comparison, the patients in the experimental group had significantly higher mini-mental state examination scores, communicative activities in daily living scores, aphasia battery of Chinese scores, quality of life scores, effective rates, and satisfaction, and significantly lower mental status scale in nonpsychiatric settings scores, National Institutes of Health Stroke Scale scores and adverse reaction rates, which was statistically significant (P < .05 in all cases). The combination treatment of scalp electroacupuncture and rehabilitation training can effectively improve the language function and quality of life of patients with aphasia after head injury and remarkably enhance the treatment effect.

Functional recovery of working-age patients with traumatic brain injury stratified in 30-day periods since head trauma to rehabilitation admission.

We stratified 213 patients with traumatic brain injury according to their time to rehabilitation admission in three groups (0-30 days, 31-60 and 61-90) in order to (1) compare total Functional Independence Measure efficiency and effectiveness between groups; (2) analyze time to admission as predictor of TFIM at discharge. After adjusting for age, Glasgow Coma Scale (GCS), Disability Rating Scale (DRS) and sex, 0-30 had the highest TFIM efficiency compared with 31-60 (P < 0.001) and 61-90 (P < 0.001), 31-60 was quasi-significantly (P = 0.051) higher than 61-90. After adjusting for age, GCS, DRS and sex, 0-30 had the highest TFIM mean effectiveness when compared with 31-60 (P = 0.004) and 61-90 (P < 0.001). Thirty-one to 60 was significantly higher (P = 0.041) than 61-90. Almost half of the variance was explained by regression models containing time to admission as predictor of TFIM at discharge. Time to admission was key to obtain significant differences in TFIM efficiency, effectiveness and in predicting TFIM at discharge.

Short term outcomes of children with abusive head trauma two years post injury: A retrospective study.

PURPOSE: Abusive head trauma (AHT) can have debilitating sequelae for children who survive. A retrospective medical record review was used to describe short-term developmental outcomes of children with AHT and identify predictors of poorer outcomes. METHOD: Children with AHT who received follow up by the hospital's rehabilitation department for 12 to 24 months post-injury were included in this review. Data for 85 children were collected on hearing, vision, gross motor, fine motor, speech and language, cognition, play, adaptive functioning, behaviour and personal-social skills. RESULTS: Global assessment found 42% of children had a good recovery, 34% had a moderate disability and 24% had a severe disability. For whom there was data, more than half had abnormal cognition, behaviour and personal-social skills, whilst more than a third had abnormal speech and language, neurological signs on last assessment, vision, play skills, and gross and fine motor skills. Factors that predicted poorer prognosis across all developmental domains included paediatric intensive care unit admission, longer length of hospital stay, breathing difficulty and lower Glasgow Coma Scale on presentation. CONCLUSION: This study highlights the substantial number of children who have abnormal development in the short-term post-AHT and assists in identifying those who require extensive long-term follow up.

[Midnight-noon ebb-flow acupuncture combined with rehabilitation therapy for severe craniocerebral trauma patients with vegetative state: a randomized controlled trial].

OBJECTIVE: To compare the clinical therapeutic effect of midnight-noon ebb-flow acupuncture combined with rehabilitation therapy and simple rehabilitation therapy in severe craniocerebral trauma patients with vegetative state. METHODS: A total of 100 patients were randomized into an observation group and a control group, 50 cases in each one. Basic treatment of medication, hyperbaric oxygen therapy and specialized nursing were given in both groups. In the control group, rehabilitation therapy was adopted for 30 min each time, once a day. On the basis of the control group, midnight-noon ebb-flow acupuncture was applied in the observation group, the needles were sustained for 30 min, once a day, 5 times a week. The treatment was for 30 days in both groups. Before treatment and after 10, 20, 30 days of treatment, scores of Glasgow coma scale (GCS) and coma recovery scale-revised (CRS-R) were observed, and the conscious rate after treatment was calculated in both groups. RESULTS: Compared before treatment, the GCS and CRS-R scores after 10, 20, 30 days of treatment were increased in both groups (P<0.01), and the scores in the observation group were superior to those in the control group (P<0.01). After treatment, the conscious rate was 20.0% (10/50) in the observation group, which was superior to 12.0% (6/50) in the control group (P<0.01). CONCLUSION: Midnight-noon ebb-flow acupuncture combined with rehabilitation therapy can effectively treat the severe craniocerebral trauma patients with vegetative state, improve the consciousness level, and have superior therapeutic effect compared with simple rehabilitation therapy.

[The ability to recover cerebral function after an isolated craniocerebral trauma]. / Sposobnost' k aktivnym deistviiam pri izolirovannoi cherepno-mozgovoi travme.

This article is devoted to the review of the literature regarding a current issue in forensic medical practice - the ability of victims to recover cerebral function after traumatic brain injury. Based on the study and analysis of data from specialized literature and clinical and expert observations, we present the basic systemized information on the recovery of consciousness, and therefore the potential for cerebral function, in victims of traumatic brain injury.

The effect of olfactory training on odor identification in patients with traumatic anosmia.

BACKGROUND: This study investigates the effect of olfactory training on odor identification in patients with traumatic anosmia. METHODS: Patients with a clear history of loss of smell after head injury, and whose phenyl ethyl alcohol (PEA) odor detection thresholds remained at -1 after steroid and zinc treatment, were included in this study between July 2016 and July 2018. They were randomly divided into 2 groups, with patients in the 4-odorant group given 4 bottles of PEA, lemon, eucalyptus, and clove oils and those in the PEA group given a bottle of PEA for 6-month olfactory training. After 3-month and 6-month training, the olfactory function was evaluated by both the PEA threshold test and the traditional Chinese version of the University of Pennsylvania Smell Identification Test (UPSIT-TC). Magnetic resonance imaging was performed to measure the volume of olfactory bulbs after training. RESULTS: There were 45 patients completing 4-odorant training and another 45 completing PEA training. The birhinal PEA threshold decreased significantly in both groups after 6-month training, but the decrease was not significantly different between the 2 groups. The UPSIT-TC score increased significantly in the PEA group but not in the 4-odorant group. The volume of olfactory bulbs was not significantly different between these 2 groups. CONCLUSION: Our results show that olfactory training can slightly improve odor threshold levels in patients with traumatic anosmia, but did not improve the odor identification ability. Nevertheless, clinical improvement or benefit in quality of life from olfactory training needs further investigation.

[Megapolis medical rehabilitation system of elderly patients with severe cranio-cerebral injury.]

The capacities of systemic standard graded medical rehabilitation were assessed in 469 patients carried out surgical intervention for severe craniocerebral injury at Saint-Petersburg hospitals in 2010-2017. As a result of neurorehabilitation system introduction rates of infectious-inflammatory complications associated with physical inactivity were significantly decreased. An average length of stay at hospital was decreased from 34±5 to 23±4 days. At discharge from neurosurgical hospital the Barthel index of activities of daily living was 42±8 points. After inpatient rehabilitation course an average Barthel index was increased to 70±6 points. And after outpatient rehabilitation course an average Barthel index had reached 70±6 points.

Head and neck burns are associated with long-term patient-reported dissatisfaction with appearance: A Burn Model System National Database study.

INTRODUCTION: Burns affecting the head and neck (H&N) can lead to significant changes in appearance. It is postulated that such injuries have a negative impact on patients' social functioning, quality of life, physical health, and satisfaction with appearance, but there has been little investigation of these effects using patient reported outcome measures. This study evaluates the effect of H&N burns on long-term patient reported outcomes compared to patients who sustained burns to other areas. METHODS: Data from the National Institute on Disability, Independent Living, and Rehabilitation Research Burn Model System National Database collected between 1996 and 2015 were used to investigate differences in outcomes between those with and without H&N burns. Demographic and clinical characteristics for adult burn survivors with and without H&N burns were compared. The following patient-reported outcome measures, collected at 6, 12, and 24 months after injury, were examined: satisfaction with life (SWL), community integration questionnaire (CIQ), satisfaction with appearance (SWAP), short form-12 physical component score (SF-12 PCS), and short form-12 mental component score (SF-12 MCS). Mixed regression model analyses were used to examine the associations between H&N burns and each outcome measure, controlling for medical and demographic characteristics. RESULTS: A total of 697 adults (373 with H&N burns; 324 without H&N burns) were included in the analyses. Over 75% of H&N injuries resulted from a fire/flame burn and those with H&N burns had significantly larger burn size (p<0.001). In the mixed model regression analyses, SWAP and SF-12 MCS were significantly worse for adults with H&N burns compared to those with non-H&N burns (p<0.01). There were no significant differences between SWL, CIQ, and SF-12 PCS. CONCLUSIONS: Survivors with H&N burns demonstrated community integration, physical health, and satisfaction with life outcomes similar to those of survivors with non-H&N burns. Scores in these domains improved over time. However, survivors with H&N burns demonstrated worse satisfaction with their appearance. These results suggest that strategies to address satisfaction with appearance, such as reconstructive surgery, cognitive behavior therapy, and social skills training, are an area of need for survivors with H&N burns.

The Relationship of Adolescent and Parent Preferences for Treatment Modality With Satisfaction, Attrition, Adherence, and Efficacy: The Coping With Head Injury Through Problem-Solving (CHIPS) Study.

OBJECTIVE: To characterize treatment preferences for delivery of family problem-solving treatment (F-PST) to adolescents with behavioral challenges following traumatic brain injury (TBI) and to examine associations with attrition, adherence, satisfaction, and efficacy. METHOD: Adolescents who had been hospitalized for moderate to severe TBI were randomized to face-to-face F-PST (n = 34), therapist-guided online F-PST (n = 56), and self-guided online F-PST (n = 60). Adolescents and parents rated treatment convenience and anticipated benefit before group assignment. Sessions completed served as an index of adherence. Satisfaction was rated posttreatment. The Behavior Rating Inventory of Executive Function and Strengths and Difficulties Questionnaire were used to assess parent-reported behavioral concerns. RESULTS: Both parents and adolescents were more likely to agree or strongly agree that they anticipated self-guided online F-PST to be the most convenient relative to either of the therapist-involved approaches. Parents were also less likely to anticipate face-to-face treatment as most beneficial, relative to the two online treatments. Adolescent preferences were significantly related to attrition with 27% versus 13% dropout rates for those assigned to nonpreferred and preferred treatments, respectively. Parent and adolescent preferences before treatment were unrelated to post-intervention satisfaction, adherence, or improvements in parent-reported child behavior problems. CONCLUSIONS: Online treatments are perceived favorably among adolescents with TBI and their parents. For adolescents, these pretreatment preferences influenced treatment completion. Poor correspondence between initial preferences and posttreatment satisfaction and benefit suggests that therapeutic experience more strongly influences ultimate satisfaction.

From meaning to symptom reduction: contemporary approaches to psychotherapy after traumatic brain injury / Del sentido a la reducción de síntomas: enfoques contemporáneos de la psicoterapia después de un trauma cráneo encefálico

Introduction: During the last decades, psychological interventions have become central components of rehabilitation programs for Traumatic Brain Injury (TBI). Nevertheless, due to a wide variability of therapeutic approaches there is little agreement regarding which approach is more suitable, or whether key elements from different psychotherapies should be integrated. This article critically reviews several contemporary approaches that are dominant in the literature. Methods: In order to accomplish such goal, an all-time search on Web of Science and Google Scholar was carried, using TBI and Psychotherapy as key words (n = 72). Results: The main finding of this paper is that theoretical and technical variability among psychotherapies reflects differences in the 'level of care' that is targeted: symptom reduction, behavioral problem reduction, quality of life and meaning reconstruction. Four contemporary approaches to psychotherapy [cognitive behavioral, third wave cognitive behavioral, narrative and psychodynamic] are then briefly described, by presenting their main theoretical tenets, the level of care they target, and the existing evidence that supports their efficacy. Finally, the implications of using a 'levels of care' perspective when addressing the 'effectiveness' debate is considered, as well as the need to familiarize future clinicians with more integrative models of psychological support after TBI.

Introducción: Durante las últimas décadas, las intervenciones psicológicas se han convertido en un elemento central de los programas de rehabilitación para personas que han adquirido un Trauma Cráneo Encefálico (TEC). Este artículo revisa críticamente los enfoques contemporáneos predominantes en la literatura a la luz del concepto de "niveles de cuidado". Método: Se realizó una revisión bibliográfica entre los años 1985 y 2014 utilizando los motores de búsqueda Web of Science y Google Scholar, usando TEC y Psicoterapia como palabras claves. 72 artículos fueron seleecionados para revisión. Resultados: Existe una amplia variabilidad teórico/técnica en los enfoques utilizados en esta población, reflejando diferencias en los niveles de cuidado: reducción de síntomas, reducción de problemas conductuales, calidad de vida y reconstrucción de sentido vital. Cuatro enfoques psicoterapéuticos contemporáneos (cognitivo-conductual, cognitivo-conductual de tercera generación, narrativo y psicodinámico) son brevemente descritos, presentando sus supuestos teóricos, el nivel de cuidado que consideran como objetivo, y la evidencia existente que apoya su efectividad. Finalmente, se discuten las implicancias de utilizar una perspectiva de 'niveles de cuidado' en el debate sobre efectividad de la psicoterapia en personas con TEC, así como la necesidad de familiarizar futuros neuropsicólogos clínicos con modelos genéricos de apoyo psicológico para esta población.

Implante de polieteretercetona para tratamiento de trauma cráneo facial y defecto / Polyetheretherketone implant for treatment of facial cranial trauma and defect

INTRODUCCIÓN: a. Cuadro clínico: Los defectos cráneo faciales pueden deberse a múltiples causas, y representan un importante reto para los neurocirujanos. Esto debido a que la corrección quirúrgica del defecto debe tener no sólo la finalidad de proteger el cerebro, sino también de lograr un resultado estético satisfactório para el paciente. El material de elección es el hueso autólogo debido a sus característica biológicas, lo que genera un menor rechazo y bajo costo. Sin embargo, existen casos en los que el uso de implantes alógenos representa una mejor opción. No existe aún consendo sobre el material de elección para los implantes autólogos habiéndose reportado diversas opciones, las más usadas son titanio y polieteretercetona (PEEK); cada uno con diferentes beneficios y limitaciones. b. Descripción de la tecnología: El PEEK es un polímero técnico termoplástico semi-cristalino usado en la fabricación de implantes. Además, se caracteriza por una rigidez y resistencia similares a las del hueso cortical. Presenta también una alta tolerancia al calor y rayos gamma, y es hipo-alergénico. En relación con otros materiales, se há reportado que el PEEK tendría como ventaja una menor toxicidad, menor riesgo de infección o exposición del implante, y no producir artefactos en las tomografias o resonancias magnéticas. Finalmente, el PEEK puede ser modelado mediante computadora o intra-operatoriamente, así como impresso con computadoras 3D. OBJETIVO: Se realizó una búsqueda sin restricciones de idioma ni fecha en las principales bases de datos bibliográficas: MEDLINE, LILACS, y COCHRANE. Adicionalmente, se hizo una búsqueda en los repositorios de agencias de evaluaciones de tecnologías sanitarias (ETS) y de guías de práctica clínica (GPC). Se dio preferencia a revisiones sistemáticas (RS) y se excluyeron reportes de casos. RESULTADOS: La estrategia de búsqueda en los repositorios arrojó 38 reportes de los cuales se seleccionó una RS. No se identificaron GPC ni ETS que mencionaran la tecnología sanitaria en evaluación, ni EE de la región. Punchack et al., realizaron una revisión sistemática para valorar la eficacia y seguridad de PEEK en craneoplastías, frente a hueso autólogo o a implante de titanio en términos de complicación y falla (infección del implante o reabsorción de plaqueta ósea, que requirieron su remoción o reemplazo). En total se incluyeron 183 pacientes a los que se les hizo craneoplastica con PEEK, con una edad promedio de 38,1 años y 59% de sexo masculino, y a los que se siguió por un promedio de 24,1 meses. La indicación más frecuente de la craneoplastía fue trauma (54,1%), el 15,3% tuvo alguma complicación, siendo la más frecuente infección con 11 casos (6%), y el 8,7% presentó falla en el implante. Se reportó menor número de complicaciones con PEEK que con el uso de hueso (0% frente a 37%; OR: 0,13; IC95%: 0,01 a 1,14; p=0,065) o implante de titanio (16,7% frente a 30,1%; OR 0,127; IC95%: 0,002 a 8,864; p=0,360); igualmente, se reportó un menor número de fallas con PEEK que con el uso de hueso (0% frente a 10,9%; OR 0,57; IC95%: 0,06 a 5,45; p=0,629) o implante de titanio (8,3% frente a 26,5%; OR: 0,17; IC95%: 0,01 a 2,11; p=0,168). En ninguno de los casos las diferencias fueron estadísticamente significativas. La RS recibió una calificación de críticamente baja calidad debido a que no cumplía con cinco de los dominios críticos. CONCLUSIONES: La evidencia que compara PEEK con hueso autólogo y otros implantes alogénicos en craneoplastía es escasa. Una revisión sistemática, con una calificación de críticamente baja calidad y escaso número de estudios y población, reportó que no hay diferencias entre PEEK y plaqueta ósea o implante de titanio en relación con la frecuencia de compliaciones o falla.(AU)

Nonsurgical Treatment for Posttraumatic Complete Facial Nerve Paralysis.

Importance: Current recommendations envisage early surgical exploration for complete facial nerve paralysis associated with temporal bone fracture and unfavorable electrophysiologic features (response to electroneuronography, <5%). However, the evidence base for such a practice is weak, with the potential for spontaneous improvement being unknown, and the expected results from alternative nonsurgical treatment also undefined. Objective: To document the results of nonsurgical treatment for posttraumatic complete facial paralysis with undisplaced temporal bone fracture and unfavorable electrophysiologic features. Design, Setting, and Participants: Prospective cohort study recruiting from April 2010 to April 2013 at a tertiary care university hospital. Follow-up continued until 9 months or until complete recovery if earlier. Study group included 28 patients with head injury-associated complete unilateral facial nerve paralysis with unfavorable results of electroneuronography (<5% response) with or without undisplaced temporal bone fracture. Undisplaced temporal bone fractures were documented in 26 patients (24 longitudinal fractures and 2 transverse fractures). Interventions: Patients received prednisolone, 1 mg/kg, for 3 weeks combined with clinical monitoring every 2 weeks and electromyography monitoring every 4 weeks. As per study protocol, surgical exploration was limited to patients demonstrating motor end plate degeneration on results of electromyography, or having no improvement until 18 weeks. Main Outcomes and Measures: Facial nerve function was evaluated by the House-Brackmann grading system; Forehead, Eye, Mouth, and Associated defect grading system; and the modified Adour system. Observations were completed at 40 weeks. Results: Among the 28 patients in the study (3 women and 25 men; mean [SD] age, 32.2 [8.7] years), facial nerve recovery with conservative treatment alone was noted in all patients. No recovery was seen in any patient at the initial 4-week review. The first signs of clinical recovery were noted in 4 patients by 8 weeks, in 27 patients by 12 weeks, and in all patients by 20 weeks. No patient required surgical exploration. At 40 weeks, 27 patients recovered to House-Brackmann grade I/II and 1 patient to grade III. All 24 patients with longitudinal fractures had grade I/II recovery. Conclusions and Relevance: For undisplaced temporal bone fractures, nonsurgical treatment leads to near-universal recovery to House-Brackmann grade I/II and is superior to reported surgical results. Recovery is delayed and usually first manifests at 8 to 12 weeks after the fracture. In the current era of high-resolution computed tomography, surgical exploration should not be first-line treatment for undisplaced longitudingal temporal bone fractures associated with complete facial nerve paralysis and unfavorable electrophysiologic features.

From conception to evaluation of mobile services for people with head injury: A participatory design perspective.

Adults with cognitive impairments lack the means to organise their daily life, plan their appointments, cope with fatigue, and manage their budget. They manifest interest in using new technologies to be part of society. Unfortunately, the applications offered on smart phones are often beyond their cognitive abilities. The goal of this study was to design a mobile cognitive assistant to enhance autonomy of people living with acquired traumatic brain injury. Participatory design methodologies guided this research by involving adults with cognitive impairments (CI) and their caregivers in the early stages of the design process. The population of the study is composed of four male adults who present cognitive impairments (three with head injury and one with stroke) and three caregivers. The first phase of this research was to design the Services Assistance Mobile and Intelligent (SAMI) application based on the needs expressed by the participants. During three focus groups, needs emerged concerning planning, health monitoring and money management and led to the implementation of assistive solutions on an Android mobile phone. During the second phase, the participants evaluated the mobile assistant SAMI at home for eight weeks. The results demonstrate that the participants were able to participate actively in the conception of SAMI and to use it successfully. People with CI showed a slight improvement in their life satisfaction. Due to the small number of participants, these promising results need to be confirmed by a larger-scale study.

[Head trauma patients, towards a new life project]. / Patient traumatisé crânien, vers un nouveau projet de vie.

A real transition between intensive care and traditional rehabilitation, the post-intensive care rehabilitation service for patients with brain injuries aims to provide patients with early and intensive rehabilitation. Multi-disciplinary teams support the patients and their families on their journey towards new life projects.

[Head trauma patients and their life course]. / Le patient traumatisé crânien et son parcours de vie.

A traumatic brain injury constitutes a complex treatment situation. Nurses are on the frontline having to assume a difficult position between idealism and fatalism with regard to the care pathway and quality of life. Taking a long-term approach to the care and systemised feedback from the patients form simple and economical levers for improvement.

[From rehabilitation to re-adaptation, preparing the return home]. / De la rééducation à la réadaptation, préparer le retour à domicile.

After a serious head trauma, the return home constitutes a key moment in the patient's reintegration. It is prepared by a multi-disciplinary team throughout the rehabilitation and re-adaptation process, taking into account the patient's prognosis for recovery.

Improving access to pediatric neurorehabilitation for patients with moderate and severe head injuries.

INTRODUCTION: The majority of severely injured children in England have a significant head injury and will be seen in Major Trauma Centers (MTCs). The period following brain injury represents an opportunity to influence recovery of neurological function. The study sought to determine whether children who had sustained a head injury were referred for neurorehabilitation. METHOD: The study was conducted over one year at one center. Children sustaining a moderate or severe head injury were identified and compared to those referred for neurorehabilitation. RESULTS: A total of 41 patients were identified; 16/41 (39%) were referred for neurorehabilitation. Group comparison revealed significant associations between referral status and age (X2(3) = 8.35, p = 0.039), injury mechanism (X2(1) = 8.12, p = 0.017), injury severity (X2(1) = 21.3, p < 0.000), and imaging findings (X2(1) = 11.71, p = 0.001). DISCUSSION: Data reveal concerns for access to neurorehabilitation. Improved access to neurorehabilitation permitting long-term follow-up is required. The establishment of MTCs provides an opportunity to enact this.

[NEW OPPORTUNITIES IN NEURO-REHABILITATION: ROBOT MEDIATED THERAPY IN CONDITONS POST CENTRAL NERVOUS SYSTEM IMPAIRMENTS]. / A NEUROREHÁBILITÁCIÓ ÚJABB LEHETOSÉGEI: TERÁPIÁS ROBOTOK ALKALMAZÁSA KÖZPONTI IDEGRENDSZERI KÁROSODÁS UTÁNI ÁLLAPOTOKBAN.

Decreasing the often-seen multiple disabilities as a consequence of central nervous system impairments requires broadening of the tools of rehabilitation. A promising opportunity for this purpose is the application of physiotherapy robots. The development of such devices goes back a quarter of century. Nowadays several robots are commercially available both for supporting upper and lower limb therapy. The aim is never to replace the therapists, but rather to support and supplement their work. It is worthwhile applying these devices for goal-oriented exercises in high repetition, which one physically fatiguing for the therapist or for the correction of functional movement by various strategies. Robot mediated therapy is also useful for motivation of the patient and making the rehabilitation programme more versatile. Robots can be used for assessment of the neuromotor status as well. Several clinical studies have been executed in this field, all over the world. Meta-analyses based on randomized, controlled trials show that supplementing the traditional physiotherapy with a robot-mediated component presents advantage for the patients. Further studies are necessary to clarify which modality and intensity of the exercises, in which group of patients, in which stage lead to the expected outcome.