Rehabilitation Medicine Specialists Research Articles

COVID-19 pandemic. What should Physical and Rehabilitation Medicine specialists do? A clinician's perspective.

COVID-19 pandemic is rapidly spreading all over the world, creating the risk for a healthcare collapse. While acute care and intensive care units are the main pillars of the early response to the disease, rehabilitative medicine should play an important part in allowing COVID-19 survivors to reduce disability and optimize the function of acute hospital setting. The aim of this study was to share the experience and the international perspective of different rehabilitation centers, treating COVID-19 survivors. A group of Physical Medicine and Rehabilitation specialists from eleven different countries in Europe and North America have shared their clinical experience in dealing with COVID-19 survivors and how they have managed the re-organization of rehabilitation services. In our experience the most important sequelae of severe and critical forms of COVID-19 are: 1) respiratory; 2) cognitive, central and peripheral nervous system; 3) deconditioning; 4) critical illness related myopathy and neuropathy; 5) dysphagia; 6) joint stiffness and pain; 7) psychiatric. We analyze all these consequences and propose some practical treatment options, based on current evidence and clinical experience, as well as several suggestions for management of rehabilitation services and patients with suspected or confirmed infection by SARS-CoV-2. COVID-19 survivors have some specific rehabilitation needs. Experience from other centers may help colleagues in organizing their services and providing better care to their patients.

Clinicians' Initial Experiences of Transition to Online Interdisciplinary Pain Rehabilitation During the Covid-19 Pandemic.

ObjectivePublic health legislation during the CO-VID-19 pandemic has resulted in forced transitioning to the use of remote care in order to continue the provision of pain rehabilitation worldwide. The objective of this study was to gain insight into clinicians’ initial experiences with the provision of interdisciplinary pain rehabilitation via videoconferencing.DesignObservational, cross-sectional design.ParticipantsTwelve team members (specialists in rehabilitation medicine -MD-, psychologists, physiotherapists and occupational therapists) from a tertiary expertise centre in pain rehabilitation.MethodsQuantitative and qualitative data were collected via a digital survey. Theme-based content analysis was performed for qualitative data.ResultsThe themes that emerged were: the compulsory context; prerequisites for proper use of videoconferencing methods, which are strongly associated with the clinicians’ experiences; changes experienced in specific components of pain rehabilitation; and overarching changes experienced, including opportunities and limitations (sub-themes: therapeutic relationship, system involvement, efficiency, hands-on possibilities, interdisciplinary teamwork, and formalities). Overall, clinicians expressed moderate agreement with the statements that the quality of the pain rehabilitation programme can be maintained using videoconferencing, and that the COVID-19 pandemic offers opportunities for growth and innovation in telehealth.ConclusionIt is feasible to provide valid and satisfactory pain rehabilitation via videoconferencing. This study identified facilitators and barriers to the use of videoconferencing, and great potential for integrating aspects of telehealth into standard care after the pandemic.LAY ABSTRACTLegislation during the COVID-19 pandemic forced transitioning to remote care to continue pain rehabilitation treatment. In this study, first experiences with interdisciplinary pain rehabilitation by videoconferencing were gathered. Both qualitative and quantitative data were collected from team members of a pain rehabilitation team via a digital survey. Overall, clinicians reported that videoconferencing is a valid way to continue care in times when legalisation does not allow for standard face-to-face care. Furthermore, clinicians see opportunities to integrate aspects of telehealth into standard care after the COVID-19 pandemic. However, several limitations and restrictions have been experienced, such as the lack of a physical examination and questions about long-term effectiveness of the treatment. In addition, further investigation is needed to investigate whether pain rehabilitation provided by videoconferencing reaches quality standards of regular care.

Poststroke Postural Sway Improved by Botulinum Toxin: A Multicenter Randomized Double-blind Controlled Trial

ObjectiveTo assess the effects of injecting botulinum toxin into the lower limb muscles of people with hemiparesis post stroke in terms of their sway areas. DesignA multicenter randomized double-blind trial on the effects of active botulinum toxin treatment vs placebo. SettingClinical examinations and postural sway assessments were performed before botulinum toxin injection and again 4-6 weeks after the injection. ParticipantsPeople with hemiparesis with chronic post stroke lower limb spasticity (N=40). InterventionsIntramuscular injection of a placebo (physiological serum) was performed on the control group, and botulinum toxin injections were performed on the treatment group. Participants and physical and rehabilitation medicine specialists were given no information as to which of the 2 treatments was applied. Main Outcome MeasuresThe sway area of the center of pressure was recorded for 30 seconds in 3 conditions: eyes open, eyes open in a dual task (a postural control task combined with an arithmetic task), and eyes closed. Spasticity was measured using the Modified Ashworth Scale. ResultsForty people post stroke were enrolled and randomized into 2 groups, one of which was treated with botulinum toxin (n=19) and the other with placebo (n=21). Spasticity decreased significantly in the treatment group (−0.7, P=.049 in the soleus muscles; −0.8, P=.035 in the gastrocnemii muscles). The sway area did not differ significantly between the 2 groups before treatment. The most conspicuous effect was observed in the case of the dual task, where a significant decrease (P=.005) in the sway area occurred in the treatment group (−3.11±6.92) in comparison with the placebo group (+0.27±3.57). ConclusionTreating spasticity by injecting botulinum toxin into people’s lower limb muscles post stroke seems to improve their postural sway. The dual task used here to assess sway seems to be a useful, sensitive test for this purpose.

Clinical Practice Guideline for Cardiac Rehabilitation in Korea.

BackgroundThough clinical practice guidelines (CPGs) for cardiac rehabilitation (CR) are an effective and widely used treatment method worldwide, they are as yet not widely accepted in Korea. Given that cardiovascular disease is the second leading cause of death in Korea, it is urgent that CR programs be developed. In 2008, the Government of Korea implemented CR programs at 11 university hospitals as part of its Regional Cardio-Cerebrovascular Center Project, and 3 additional medical facilities will be added in 2019. In addition, owing to the promotion of CR nationwide and the introduction of CR insurance benefits, 40 medical institutions nationwide have begun CR programs even as a growing number of medical institutions are preparing to offer CR. The purpose of this research was to develop evidence-based CPGs to support CR implementation in Korea.MethodsThis study is based on an analysis of CPGs elsewhere in the world, an extensive literature search, a systematic analysis of multiple randomized control trials, and a CPG management, development, and assessment committee comprised of 33 authors—primarily rehabilitation specialists, cardiologists, and thoracic surgeons in 21 university hospitals and 2 general hospitals. Twelve consultants, primarily rehabilitation, sports medicine, and preventive medicine specialists, CPG experts, nurses, physical therapists, clinical nutritionists, and library and information experts participated in the research and development of these CPGs. After the draft guidelines were developed, 3 rounds of public hearings were held with staff members from relevant academic societies and stakeholders, after which the guidelines were further reviewed and modified.ResultsCR involves a more cost-effective use of healthcare resources relative to that of general treatments, and the exercise component of CR lowers cardiovascular mortality and readmission rates, regardless of the type of coronary heart disease and type and setting of CR.ConclusionIndividualized CR programs should be considered together with various factors, including differences in heart function and lifestyle, and doing so will boost participation and adherence with the CR program, ultimately meeting the final goals of the program, namely reducing the recurrence of myocardial infarction and mortality rates.

Inter-rater reliability and variability of ultrasound measurements of abdominal muscles and fasciae thickness.

Ultrasound (US) imaging is being increasingly used by Physical and Rehabilitation Medicine (PRM) specialists to measure the thickness of abdominal muscles. The current study set out to assess the inter-rater reliability of US measurements of the thickness of the abdominal muscles/fasciae. Three raters (1 = orthopedic specialist, expert on fasciae; 2 = PRM resident; 3 = PRM specialist) with different levels of US training examined the abdominal muscles and fasciae of a healthy volunteer under supine resting and dynamic conditions following a standard US protocol. The probe was positioned along the right lateral abdominal wall at the height of the 12th rib: (1) above the umbilicus at the linea alba, (2) to the side of and approximately 2 cm from the umbilicus, (3) along the mammillary line, and (4) along the anterior axillary line. Each rater measured 17 anatomical structures six times during two sessions. The relative error of the measurements (intra-rater variability) was slightly higher for the fasciae than for the muscles, and during the dynamic condition than the resting condition. Inter-rater reliability was good under both conditions for the fasciae (Intraclass Correlation Coefficient = ICC = 0.83) and excellent for the muscles (ICC = 0.99). Knowledge of the fascial anatomy of the abdominal wall is essential for accurate ultrasound examinations and for improving reliability. These findings confirm that US imaging is a reliable, non-invasive, cost-effective instrument for evaluating the abdominal muscles/fasciae. Clin. Anat. 32:948-960, 2019. © 2019 Wiley Periodicals, Inc.

Clinical Practice Guideline for Cardiac Rehabilitation in Korea.

ObjectiveThough clinical practice guidelines (CPGs) for cardiac rehabilitation (CR) are an effective and widely used treatment method worldwide, they are as yet not widely accepted in Korea. Given that cardiovascular disease is the second leading cause of death in Korea, it is urgent that CR programs be developed. In 2008, the Government of Korea implemented CR programs at 11 university hospitals as part of its Regional Cardio-Cerebrovascular Center Project, and three additional medical facilities will be added in 2019. In addition, owing to the promotion of CR nationwide and the introduction of CR insurance benefits, 40 medical institutions nationwide have begun CR programs even as a growing number of medical institutions are preparing to offer CR. The purpose of this research was to develop evidence-based CPGs to support CR implementation in Korea.MethodsThis study is based on an analysis of CPGs elsewhere in the world, an extensive literature search, a systematic analysis of multiple randomized control trials, and a CPG management, development, and assessment committee comprised of 33 authors—primarily rehabilitation specialists, cardiologists, and thoracic surgeons in 21 university hospitals and two general hospitals. Twelve consultants, primarily rehabilitation, sports medicine, and preventive medicine specialists, CPG experts, nurses, physical therapists, clinical nutritionists, and library and information experts participated in the research and development of these CPGs. After the draft guidelines were developed, three rounds of public hearings were held with staff members from relevant academic societies and stakeholders, after which the guidelines were further reviewed and modified.Principal ConclusionsCR involves a more cost-effective use of healthcare resources relative to that of general treatments, and the exercise component of CR lowers cardiovascular mortality and readmission rates, regardless of the type of coronary heart disease and type and setting of CR. Individualized CR programs should be considered together with various factors, including differences in heart function and lifestyle, and doing so will boost participation and adherence with the CR program, ultimately meeting the final goals of the program, namely reducing the recurrence of myocardial infarction and mortality rates.

Clinical Practice Guideline for Cardiac Rehabilitation in Korea: Recommendations for Cardiac Rehabilitation and Secondary Prevention after Acute Coronary Syndrome.

Though clinical practice guidelines (CPGs) for cardiac rehabilitation (CR) are an effective and widely used treatment method worldwide, they are as yet not widely accepted in Korea. Given that cardiovascular (CV) disease is the second leading cause of death in Korea, it is urgent that CR programs be developed. In 2008, the Government of Korea implemented CR programs at 11 university hospitals as part of its Regional Cardio-Cerebrovascular Center Project, and 3 additional medical facilities will be added in 2019. In addition, owing to the promotion of CR nationwide and the introduction of CR insurance benefits, 40 medical institutions nationwide have begun CR programs even as a growing number of medical institutions are preparing to offer CR. The purpose of this research was to develop evidence-based CPGs to support CR implementation in Korea. This study is based on an analysis of CPGs elsewhere in the world, an extensive literature search, a systematic analysis of multiple randomized control trials, and a CPG management, development, and assessment committee comprised of thirty-three authors—primarily rehabilitation specialists, cardiologists, and thoracic surgeons in 21 university hospitals and 2 general hospitals. Twelve consultants, primarily rehabilitation, sports medicine, and preventive medicine specialists, CPG experts, nurses, physical therapists, clinical nutritionists, and library and information experts participated in the research and development of these CPGs. After the draft guidelines were developed, 3 rounds of public hearings were held with staff members from relevant academic societies and stakeholders, after which the guidelines were further reviewed and modified. CR involves a more cost-effective use of healthcare resources relative to that of general treatments, and the exercise component of CR lowers CV mortality and readmission rates, regardless of the type of coronary heart disease and type and setting of CR. Individualized CR programs should be considered together with various factors, including differences in heart function and lifestyle, and doing so will boost participation and adherence with the CR program, ultimately meeting the final goals of the program, namely reducing the recurrence of myocardial infarction and mortality rates.

Rehabilitation possibilities and results after neurosurgical intervention of brain tumors

Authors examined the rehabilitation possi-bi-lities, necessities, and results of patients after operation with brain tumor, and report their experiences. Retrospective, descriptive study at the Brain Injury Rehabilitation Unit, in National Institute for Medical Rehabilitation. Patients were admitted consecutively after rehabilitation consultation, from different hospitals, following surgical intervention of brain tumors, between 01 January 2001 and 31 December 2016. Patients participated in a postacute inpatient rehabilitation program, in multidisciplinary team-work, leaded by Physical and Rehabilitation Medicine specialist included the following activities: rehabilitation nursing, physical, occupational, speech, psychological and neuropsychological therapy. At the rehabilitation unit, in the sixteen-year period 84 patients were treated after operation with brain tumor. Patients arrived at the unit after an average of 41 days to the time of the surgical intervention (range: 10-139 days), and the mean length of rehabilitation stay was 49 days (range: 2-193 days). The mean age of patients was 58 years (20-91), who were 34 men and 50 women. The main symptoms were hemiparesis (64), cognitive problems (26), dysphagia (23), aphasia (16), ataxia (15), tetraparesis (5), and paraparesis (1). The mean Barthel Index at the time of admission was 35 points, whereas this value was 75 points at discharge. After the inpatient rehabilitation, 73 patients improved functionally, the status of 9 patients did not show clinically relevant changes, and 2 patients deteriorated. During the rehabilitation 10 patients required urgent interhospital transfer to brain surgery units, 9 patients continued their oncological treatment, two patients continued rehabilitation treatment at another rehabilitation unit, and after rehabilitation 73 patients were discharged to their homes. Inpatient rehabilitation treatment could be necessary after operation of patients with brain tumor especially when functional disorders (disability) are present. Consultation is obligatory among the neurosurgeon, rehabilitation physician and the patient to set realistic rehabilitation goals and determine place and method of rehabilitation treatment, but even at malignancies cooperation with oncological specialist also needed. Authors' experience shows benefits of multidisciplinary rehabilitation for patients after brain tumor surgery.

Effects of Ultrasound Therapy on Balance and Gait in Stroke Patients with Gastrocnemius Muscle Spasticity

The purpose of this study is to investigate the effect of ultrasound therapy on calf muscle spasticity of stroke patients. Ten patients who were diagnosed with stroke by a specialist in rehabilitation medicine were divided into two groups by random assignment method. The control group received a 10-minute ultrasound placebo effect after general physiotherapy. In the experimental group, ultrasound therapy was given for 10 minutes after general physical therapy. In this study, muscle tone was assessed using MAS(modified ashworth scale), balance was assessed using TUG(time up amp go), and gait was assessed using a 10m walk test. There was a significant difference between the experimental group and the muscle tone, balance, and gait. However, there was no significant difference in the control group. There was a significant difference between the groups in balance and gait, but not in muscle tone. Ultrasound therapy should be adapted to reduce spasticity and improve function in stroke patients.

Rehabilitation strategies after 2004 Aceh earthquake and tsunami disaster in Indonesia: Case report

December 26, 2004 an earthquake with a magnitude of 8,9 SR US followed by tsunami has hit the west and north coast of Nangroe Aceh Darussalam (NAD) province and North Sumatra region in Indonesia. Hundreds of thousands has been dead, many more have been injured, it also caused damaged to almost every infrastructures including health services. Health problem related to earthquake and tsunami other than respiratory problems are multiple bone fractures, peripheral nerve injuries, severe infected wounds, gangrenes that often lead to amputation of the injured limbs. The only rehabilitation centre in Aceh province at Zainoel Abidin hospital in Banda Aceh, have been damaged seriously including all equipments for mobility and the prosthesis-orthosis workshop. Many limb amputee persons, has great need for prosthesis so they can walk and do their daily living activity. Prosthesis manufactures need special skill and are individually design. After early assessment, a special rehabilitation medicine team together with an international NGO, work for relief after disaster, made and distribute free prosthetic-orthotics. From April 24, 2005 till March 29, 2006 the rehabilitation medicine team and prosthetic-orthotic technicians has made seven visits to Banda Aceh and approximately for three to four days on each visit. The team made and give one hundred fifty (150) free prosthesis-orthosis appliances for 134 amputee. All these prosthetic-orthotic appliances was made at the orthotic-prosthetic laboratory. Department of Rehabilitation Medicine, Cipto Mangunkusumo teaching hospitals in Jakarta. There is a great need to rebuilt rehabilitation medicine services in Aceh with its infrastructures, equipments and specialized trained person such as rehabilitation medicine specialist and prosthetic-orthotic technician. Long-term plan from rehabilitation medicine view are to develop a mobile limb workshop for rehabilitation medicine services, so an outreach program can be done more effectively.

Rehabilitation in the core graduate medical curricula at university of São Paulo school of medicine: The student's perception

Rehabilitation is a key health strategy for the 21st century. Increase the number of medical graduates aware of rehabilitation competencies and skills is a success indicator of strengthening and extending the provision of rehabilitation services. Our objective was to evaluate a novel teaching method to third year medical students based mostly in student-centered techniques. This course was offered at Faculdade de Medicina da Universidade de São Paulo, Brazil. One hundred sixty-eight third year medical students responded an anonymous survey evaluating their perception of a 12-hour discipline on Rehabilitation. The Discipline was developed collaboratively in the 2017 Medical Teaching and Learning Innovation Program. Teaching materials were available to students at an educational platform to promote interaction and collaboration. The didactic curriculum was presented in the case-method format. Students performed the anamnesis and physical examination, with emphasis on the functional semiology, developing a treatment plan with functional goals, under the supervision of physical and rehabilitation medicine specialists, who mentored the activities. Members of the multidisciplinary team participated in the discussions. Rehabilitation interventions were performed as needed. Students were requested to produce and to present a mental map of the evaluated cases. 95.3% of the students responded the anonymous survey. 88.2% of the responding students considered rehabilitation as an important discipline in medical training. For 90.8% of the students, the overall assessment for the course was “very good” or “good” and 59.6% requested the increase in its duration. Third year medical students perceive rehabilitation as an important discipline in medical education. The overall assessment for the course was “very good” or “good”, and there is a request for the increase in its duration from more than half of the students. Improvement of course methodology in rehabilitation may improve to attract more medical students to rehabilitation specialty.

2017 Bangladesh landslides: Physical rehabilitation perspective

This report characterizes traumatic rehabilitation injuries due to the 2017 Bangladesh landslides. Emergency care for rehabilitation conditions provided by field respondents, at receiving community treatment centers, district and at regional hospital(s) is described. Recommendations to improve rehabilitative care in future landslides are provided. Landslides are triggered by external processes including earthquakes, rainstorms, and slope disturbance by humans. Humans are highly vulnerable to the high energy forces of sliding earth and debris which can result in severe traumatic physical injury and death. Landslides triggered by torrential seasonal monsoon rain began early June 2017 and severely affected 42,000 persons in several hilly and coastal districts of Bangladesh. An electronic literature search was performed to identify relevant articles on landslides in Bangladesh, Southeast Asia, and other developing countries. Reports from government and non-governmental sources including relevant hospital admissions data were obtained and analyzed. Information was also obtained through personal communications with local health and emergency management officials and from local and international media sources The 2017 Bangladesh landslides resulted in 172 deaths and 11 missing persons. Thousands of persons received first aid from responding medical teams. Of the 194 persons admitted to district hospitals for severe injuries, 33.50% of injuries treated were musculoskeletal conditions. Twelve (12) persons with critical injuries including long bone fracture, spinal injury, and head injury were referred to a regional tertiary hospital for management by neurology, orthopedic surgery, physical Rehabilitation medicine and psychiatry specialists. Landslides can result in severe traumatic injuries. Rehabilitative treatment with involvement of physiatrists should be provided at all levels of emergency care. Specialized rehabilitation response teams should be employed in landslides and other severe natural disasters in Bangladesh.

White Book on Physical and Rehabilitation Medicine (PRM) in Europe. Chapter 9. Education and continuous professional development: shaping the future of PRM.

In the context of the White Book of Physical and Rehabilitation Medicine (PRM), this paper deals with the education of PRM physicians in Europe. To acquire the wide field of competence needed, specialists in Physical and Rehabilitation Medicine have to undergo a well organised and appropriately structured training of adequate duration. In fact they are required to develop not only medical knowledge, but also competence in patient care, specific procedural skills, and attitudes towards interpersonal relationship and communication, profound understanding of the main principles of medical ethics and public health, ability to apply policies of care and prevention for disabled people, capacity to master strategies for reintegration of disabled people into society, apply principles of quality assurance and promote a practice-based continuous professional development. This paper provides updated detailed information about the education and training of specialists, delivers recommendations concerning the standards required at a European level, in agreement with the UEMS rules of creating a Common Training Framework, that consists of a common set of knowledge, skills and competencies for postgraduate training. The role of the European PRM Board is highlighted as a body aimed at ensuring the highest standards of medical training and health care across Europe and the harmonization of PRM physicians' qualifications. To this scope, the theoretical knowledge necessary for the practice of PRM specialty and the core competencies (training outcomes) to be achieved at the end of training have been established and the postgraduate PRM core curriculum has been added. Undergraduate training of medical students is also focused, being considered a mandatory element for the growth of both PRM specialty and the medical community as a whole, mainly in front of the future challenges of the ageing population and the increase of disability in our continent. Finally, the problems of continuing professional development and medical education are faced in a PRM European perspective, and the role of the European Accreditation Council of Continuous Medical Education (EACCME) of UEMS is outlined.

Perception of the role of physical and rehabilitation medicine among physiotherapy students.

To determine how the role of physical and rehabilitation medicine specialists in healthcare is perceived by physiotherapy students. Cross-sectional observational study. A total of 677 physiotherapy students and 519 final year medical students at the largest university-level educational institutions in Warsaw, Poland. Questionnaire about knowledge of the role of physical and rehabilitation medicine specialists in the healthcare system. The definition of physical and rehabilitation medicine specialists was known to 32.9% of medical students and 19.9% of physiotherapy students. Misconceptions most frequently resulted from an inability to distinguish physical and rehabilitation medicine from physiotherapy. The leading role of physical and rehabilitation medicine specialists in team management of persons with disabilities was identified by 25.4-55.5% of medical and 5.8-9.0% of physiotherapy students. Inadequate perception of the role of physical and rehabilitation medicine specialists in healthcare may result from recent changes in the management of rehabilitation services, tendencies towards professional independence among health professionals, and insufficient formative education. Perception of the role of physical and rehabilitation medicine specialists in healthcare was found to be inadequate among physiotherapy students. Changes in health professional education are warranted to maintain an effective patient-centred collaborative practice. Further research is needed at national and international levels to address the mutual perception of competencies and roles among students of health professions.

Challenging management of patients with functional symptoms for the physical and rehabilitation medicine specialist: What can we learn from literature?

Functional symptoms (FS) are symptoms for which no “organic” cause is found. They could concern a significant part of physical and rehabilitation medicine (PRM) patients, since they represent 25 to 50% of all symptoms in primary care. Their management is challenging, often generating negative emotions during medical encounter. Their prognosis usually appears to be unfavorable. Is FS treatment worthwhile if the results are so uncertain? How could we be more efficient? Is the referral to a psychiatrist imperative? This literature review attempts to answer to those questions applied to PRM. The MeSH terms «Somatoform Disorders», «Physical and Rehabilitation Medicine», «Prognosis», «Treatment» and «Health Care Costs» were used on PubMed database to find the most recent and relevant articles enlightening the FS management. FS create incongruence between patients’ symptoms and doctors’ explanatory models for biomedical diseases. The explanation is however the key aspect of the diagnostic process. Psychosocial issues relating to the symptoms can bring elements to find congruence between patients’ and practitioners’ views. FS management includes physical rehabilitation that should integrate a cognitive behavioral therapy. Antidepressants are to be considered. Referral to a psychiatrist is a second line treatment. Mindfulness-based cognitive therapy is an arising and promising method for FS. Intensive multidisciplinary treatment is adapted for chronic and severe FD. FS are associated with relevant direct and indirect costs strongly depending on symptoms severity. This burden justifies the allocation of sufficient resources. FS management is based on a positive doctor–patient relationship made of trust, partnership and support. Cognitive behavioral therapy is actually an essential ongoing process that PRM specialists should conduct. It helps patients to think about and to respond to their symptoms differently. Teaching interviewing and information-giving skills to medical students could improve their ability to deal with illnesses beyond the only goal of treating diseases. In conclusion, FS management suggests a conceptual move from curing to caring and coping. Cognitive behavioral therapy is not restricted to psychiatrists. Studies about patients with functional disability in the field of PRM are lacking and no specific recommendations are yet available.

Physical Therapy and Manual Therapy for Prevention and Rehabilitation of Cervical Myofascial Pain and Headache, due to Spine Malposition in Users (Abusers) of Smart Phones

Introduction: Ultimately, the introduction of portable devices in the everyday life imposed the necessity to evaluate the possible consequences (of the abuse) on the position of the spine and correspondent structures of the nervous system. Medical specialists are responsible for the construction of programs for prevention of these consequences. The goal of the current article is to evaluate the impact of physical therapy and manual therapy in the treatment and the prevention of cervical myofascial pain and headache, due to spinal malposition in users (abusers) of smart phones. Materials and methods: We observed a total of 69 patients with cervical myofascial pain and headache. The age of the patients was between 19 and 49 years, with posture (position) alterations of the cervical spine, but without significant cervical pathology. All patients used a mobile device in their everyday activities (minimum 2 h daily) for at least 6 months. Functional evaluation was effectuated before, during and after treatment and one month after the end of the rehabilitation. In all patients we applied a complex physical-therapeutic program, including analytic exercises for paravertebral muscles and soft tissue techniques [massages, post-isometric relaxation (PIR) for the respective upper trapezius and sterno-cleido-mastoideus muscle] and stimulation of patients’ active participation in the process of prevention (education in principles of back-school, self-massage, auto-PIR). The patients in the first group effectuated only these procedures. In the second group we added elements of manual therapy (tractions, mobilizations, manipulations; and auto-mobilizations). Statistical evaluation was performed by SPSS program, version 17; using t-test (analysis of variances ANOVA) and Wilcoxon rank test (non-parametrical correlation analysis). Results and analysis: All patients reported a significant decrease in the intensity of cervical pain and headache (evaluated by Visual analogue scale of pain and by pressure dolorimetry). In all patients we observed amelioration of the static position of the cervical spine, reduced amount of paravertebral muscle spasm and of the sensibility of trigger and tender points; and augmentation of range of active motion of the cervical region of the spine. During the rehabilitation period the results were most important in the second group (with manual therapy), but one month later there is not statistical differences between both groups. Discussion and conclusion: Techniques of physical therapy and manual therapy are very useful for the prevention and the rehabilitation processes of cervical myofascial pain and headache. The program of care includes active (analytic) exercises, PIR and stretching techniques, tractions and mobilizations, education of the patient, and (in some cases) manipulations. We consider that every medical doctor - specialist in Physical and rehabilitation medicine and every physical therapist must adapt the general algorithm to the needs of the concrete patient.

Understanding community-based rehabilitation and the role of physical and rehabilitation medicine.

Community-based rehabilitation (CBR) is an accepted model to improve the delivery of rehabilitation in the community. It includes the access to health care, education, labor and accessible environments. The role of Specialists in Physical and Rehabilitation Medicine in this strategy (SPRM) is not very well defined. On the occasion of the international consultation for the WHO Action Plan for persons with disabilities, a discussion about the meaning of CBR and the role of SPRM on CBR has occurred among the International Society of Physical and Rehabilitation Medicine (ISPRM) members. The following major questions were identified; what is CBR? What is the role of Specialists in Physical and Rehabilitation Medicine (SPMR) in CBR? A review of the literature and a discussion among experts was held to answer these questions. It is of major importance to distinguish between the two concepts of CBR: The first one is the policy or management strategy of CBR that was developed by WHO about 30 years ago. The second one is the provision of basic rehabilitation services offered at the community level. CBR strategy must also addresses the need for optimal access to specialized rehabilitation services and will have a key role in the design and building of so-called "Basic Rehabilitation Services." The authors proposed a scheme, which integrates all relevant aspects surrounding the concept of CBR; levels of care rehabilitation services and the roles proposed for SPRM. In addition, the convention for the rights of persons with disabilities and the conceptual framework of the ICF was taken into account.

回復期リハビリテーション病棟をさらに進化させるために

回復期リハビリテーション病棟をさらに進化させるために

エビデンスとロールモデルから示されるリハビリテーション科専門医の存在意義

リハビリテーション（以下，リハ）科専門医の価値を示すためには，リハ科領域だけでなく関連職種そして社会へと多方向性の戦略が求められる．リハ科専門医によって医療は，介護は，急性期は，回復期は，在宅はこんなによくなるという実感を与えなければならない．2005年よりリハ患者データバンク（DB）が開発（現在はJARDに再編）され，2015年2月現在，33,419のデータが蓄積されているが，論文化や診療報酬への活用はまだ少ない．患者や家族に対しては核となるリハ科専門医の姿（ロールモデル）を直接見せる機会を増やすことが効果的である．新専門医制度では第三者機関である認定機構による認定となった．この機会を生かし，リハ科専門医を目指す医師が増えることを願う．

Gastrointestinal risk assessment in patients requiring non-steroidal anti-inflammatory drugs for osteoarthritis: The GIRANO study.

To evaluate gastrointestinal risk profiles in patients with osteoarthritis who are currently being treated, or who are candidates for treatment, with a non-steroidal anti-inflammatory drug. Patients with osteoarthritis treated by primary care physicians or physical and rehabilitation medicine (PRM) specialists in Belgium and Luxembourg were scored for gastrointestinal risk profile, low, moderate or high, based on the presence of gastrointestinal risk factors. These included advanced age, gastrointestinal history, comorbidities, medication use, smoking, and alcohol consumption. Use of gastro-protective agents (proton pump inhibitors) was also assessed. A total of 190 primary care physicians and PRM specialists provided data on 885 patients. A large majority of patients were rated high-risk gastrointestinal (77.8%), with fewer moderate (19.4%) or low (2.8%) risk. The proportion of high-risk patients treated by PRM specialists was significantly lower than that treated by primary care physicians (64.7% vs 79.9%; p < 0.0001). Only 37.0% of high-risk patients received proton pump inhibitors co-prescription with a non-steroidal anti-inflammatory drug. A high prevalence of elevated gastrointestinal risk was found in this survey of patients with osteoarthritis who were current or candidate users of non-steroidal anti-inflammatory drugs. This appears to be insufficiently recognized, as preventative gastro-protective co-treatment was infrequently prescribed. Careful assessment of gastrointestinal risk factors should be made before prescribing non-steroidal anti-inflammatory drugs, with treatment tailored to the patient's gastrointestinal risk profile.