High-intensity exercise does not protect against orthostatic intolerance following bedrest in 55- to 65-yr-old men and women.

Prolonged bedrest provokes orthostatic hypotension and intolerance of upright posture. Limited data are available on the cardiovascular responses of older adults to head-up tilt following bedrest, with no studies examining the potential benefits of exercise to mitigate intolerance in this age group. This randomized controlled trial of head-down bedrest (HDBR) in 55- to 65-yr-old men and women investigated if exercise could avert post-HDBR orthostatic intolerance. Twenty-two healthy older adults (11 female) underwent a strict 14-day HDBR and were assigned to either an exercise (EX) or control (CON) group. The exercise intervention included high-intensity, aerobic, and resistance exercises. Head-up tilt-testing to a maximum of 15 minutes was performed at baseline (Pre-Bedrest) and immediately after HDBR (R1), as well as 6 days (R6) and 4 weeks (R4wk) later. At Pre-Bedrest, three participants did not complete the full 15 minutes of tilt. At R1, 18 did not finish, with no difference in tilt end time between CON (422 ± 287 s) and EX (409 ± 346 s). No differences between CON and EX were observed at R6 or R4wk. At R1, just 1 participant self-terminated the test with symptoms, while 12 others reported symptoms only after physiological test termination criteria were reached. Finishers on R1 protected arterial pressure with higher total peripheral resistance relative to Pre-Bedrest. Cerebral blood velocity decreased linearly with reductions in arterial pressure, end-tidal CO2, and cardiac output. High-intensity interval exercise did not benefit post-HDBR orthostatic tolerance in older adults. Multiple factors were associated with the reduction in cerebral blood velocity leading to intolerance.

Physiology of physical inactivity, sedentary behaviours and non-exercise activity: insights from the space bedrest model.

Physical inactivity, i.e. not reaching the recommended level of physical activity (PA), and sedentary behaviours (SB), i.e. sitting time, have been associated with increased risk for common metabolic diseases. Recent epidemiological data suggest that high volumes of SB are detrimental to metabolic health, even in the presence of regular exercise, i.e. moderate/vigorous PA. This suggests that the health effects of SB are independent from those of exercise. However, experimentally testing this hypothesis is complicated because of the difficulty in disassociating SB from PA. Bedrest studies, a traditional space science model, can offer new insights. In some bedrest studies, an exercise training protocol has been used to counteract the harmful effects of inactivity. While bedrest induces an inactive and sedentary state, exercise with bedrest represents a unique model of sedentary yet physically active people. Here, we review bedrest studies with and without exercise training. Although exercise training prevents the loss of muscle mass and function, even large volumes of exercise are not sufficient to fully counteract the negative metabolic adaptations triggered by inactivity. This observation supports the existence of independent adverse health effects of SB, but also the potential benefits of non-exercise activity, i.e. daily living light PA. We gathered available data to examine the complex relationships between exercise, non-exercise activity, SB and health outcomes. Given the large amount of SB in modern societies, the sole promotion of exercise, i.e. moderate/vigorous PA may be insufficient, and promotion of light PA may be a complimentary approach to improve health.

The effect of stress management training on perceived stress, anxiety and hopelessness levels of women with high-risk pregnancy.

The aim of this study was to investigate the effect of stress management training on the perceived stress, anxiety and hopelessness levels of women with high-risk pregnancy. The sample of this experimental study consisted of 206 high-risk pregnant women (intervention = 103; control = 103). Data were collected using a Personal Information Form, the Perceived Stress Scale, the Beck Hopelessness Scale and the State-Trait Anxiety Inventory. In the second follow-up after the training, there was a statistically significant difference amongst the Perceived Stress Scale, Beck Hopelessness Scale and State-Trait Anxiety Inventory mean scores in the intervention and control groups (p < .05). Perceived stress scores of the control group who did not receive training during discharge increased. The state and trait anxiety scores and hopelessness scores of the intervention group received training decreased compared with the control group.IMPACT STATEMENTWhat is already known on this subject? Mental problems such as anxiety and stress are more common in high-risk pregnancies compared with healthy pregnancies.What do the results of this study add? After the training 51.4% of women in the intervention group, 75.7% of women in the control group had stress. The state and trait anxiety and hopelessness scores of the intervention group having training decreased compared to the control group.What are the implications of these findings for clinical practice and/or further research? Health professionals should provide stress management training in high-risk pregnant women to reducing perceived stress, anxiety and hopelessness levels.

Human blood adenosine biomarkers and non-rapid eye movement sleep stage 3 (NREM3) cortical functional connectivity associations during a 30-day head-down-tilt bed rest analogue: Potential effectiveness of a reactive sledge jump as a countermeasure.

We investigated the alterations of sleep regulation and promotion biomarkers as adenosine through its enzymes total adenosine deaminase (tADA)/adenosine deaminase (ADA2) in a microgravity analogue environment of head-down-tilt bed rest and their association with brain connectivity networks during non-rapid eye movement sleep stage 3 (NREM3), as well as the effectiveness of the reactive sledge (RSL) jump countermeasure to promote sleep. A total of 23 healthy male volunteers were maintained in 6° head-down-tilt position for 30 days and assigned either to a control or to a RSL group. Blood collection and polysomnographic recordings were performed on data acquisition day 1, 14, 30 and -14, 21, respectively. Immunochemical techniques and network-based statistics were employed for adenosine enzymes and cortical connectivity estimation. Our findings indicate that human blood adenosine biomarkers as well as NREM3 cortical functional connectivity are impaired in simulated microgravity. RSL physical activity intervened in sleep quality via tADA/ADA2 fluctuations lack, minor cortical connectivity increases, and limited degree of node and resting-state networks. Statistically significant decreases in adenosine biomarkers and NREM3 functional connectivity involving regions (left superior temporal gyrus, right postcentral gyrus, precuneus, left middle frontal gyrus, left postcentral gyrus, left angular gyrus and precuneus) of the auditory, sensorimotor default-mode and executive networks highlight the sleep disturbances due to simulated microgravity and the sleep-promoting role of RSL countermeasure. The head-down-tilt environment led to sleep deterioration projected through NREM3 cortical brain connectivity or/and adenosine biomarkers shift. This decline was more pronounced in the absence of the RSL countermeasure, thereby highlighting its likely exploitation during space missions.

Society for Maternal-Fetal Medicine Consult Series #50: The role of activity restriction in obstetric management: (Replaces Consult Number 33, August 2014).

Despite current recommendations against its use, activity restriction remains a common intervention used to prevent preterm birth in multiple clinical settings. Hypertensive disorders of pregnancy, preterm premature rupture of membranes, multiple gestations, vaginal bleeding, short cervical length, placenta previa, and fetal growth restriction are also common reasons for antepartum hospital admission and frequently lead to a recommendation for activity restriction. However, numerous reports have shown that activity restriction does not prevent adverse obstetrical outcomes but does confer significant physical and psychosocial risks. This consult reviews the current literature on activity restriction and examines the evidence regarding its use in obstetrical management. The recommendations by the Society for Maternal-Fetal Medicine are as follows: (1) we recommend against the routine use of any type of activity restriction in pregnant women at risk of preterm birth based on preterm labor symptoms, arrested preterm labor, or shortened cervix (GRADE 1B); (2) we recommend against the use of routine inpatient hospitalization and activity restriction for the prevention of preterm birth in women with multiple gestations (GRADE 1A); and (3) given the lack of data definitively demonstrating that activity restriction improves perinatal outcome in pregnancies complicated by fetal growth restriction, preterm premature rupture of membranes, or hypertensive diseases of pregnancy, coupled with evidence of adverse effects of activity restriction, we suggest that activity restriction not be prescribed for the treatment of pregnancies complicated by fetal growth restriction, preterm premature rupture of membranes, or hypertensive disease (GRADE 2B).

Effects of 21 days of bed rest and whey protein supplementation on plantar flexor muscle fatigue resistance during repeated shortening contractions.

PURPOSE: Space flight and bed rest (BR) lead to a rapid decline in exercise capacity. Whey protein plus potassium bicarbonate diet-supplementation (NUTR) could attenuate this effect by improving oxidative metabolism. We evaluated the impact of 21-day BR and NUTR on fatigue resistance of plantar flexor muscles (PF) during repeated shortening contractions, and whether any change was related to altered energy metabolism and muscle oxygenation. METHODS: Ten healthy men received a standardized isocaloric diet with (n = 5) or without (n = 5) NUTR. Eight bouts of 24 concentric plantar flexions (30 s each bout) with 20 s rest between bouts were employed. PF muscle size was assessed by means of peripheral quantitative computed tomography. PF muscle volume was assessed with magnetic resonance imaging. PF muscle force, contraction velocity, power and surface electromyogram signals were recorded during each contraction, as well as energy metabolism (31P nuclear magnetic resonance spectroscopy) and oxygenation (near-infrared spectroscopy). Cardiopulmonary parameters were measured during an incremental cycle exercise test. RESULTS: BR caused 10-15% loss of PF volume that was partly recovered 3 days after re-ambulation, as a consequence of fluid redistribution. Unexpectedly, PF fatigue resistance was not affected by BR or NUTR. BR induced a shift in muscle metabolism toward glycolysis and some signs of impaired muscle oxygen extraction. NUTR did not attenuate the BR-induced-shift in energy metabolism. CONCLUSIONS: Twenty-one days' BR did not impair PF fatigue resistance, but the shift to glycolytic metabolism and indications of impaired oxygen extraction may be early signs of developing reduced muscle fatigue resistance.

Maternal activity restriction to reduce preterm birth: Time to put this fallacy to bed.

Activity restriction has traditionally been recommended to pregnant women, especially high-risk patients, to reduce preterm birth. However, there is no scientific evidence that bed-rest reduces preterm birth and, in many studies, women on bed-rest had higher rates of delivering preterm. Bed-rest in pregnancy is associated with significant physiological and psychosocial sequelae and reduced neonatal birth weight and be cannot be endorsed, even in women with a short cervix. The practice of prescribing bed-rest in pregnancy is outdated and should be abandoned.

Choosing Wisely: Bedrest-A Panacea for All That Ails the Gravida?

Bedrest has been frequently prescribed for various high-risk conditions during pregnancy. A common indication cited is concern regarding increased risk of spontaneous preterm birth, known to be associated with gestations with twins or higher-order multiples, polyhydramnios, presence of preterm contractions with or without evidence of cervical change, sonographic cervical shortening, presence of a dilated cervix with bulging membranes, or preterm premature rupture of membranes. In some cases, there is concern that excessive movement may increase the risk of antepartum hemorrhage, as may be with placenta previa, with or without a higher risk of a morbidly adherent placenta or a vasa previa. It is also thought that improved splanchnic perfusion with bedrest may enhance blood supply to the uterus with possible benefit in conditions such as preeclampsia (or gestational hypertension) or fetal growth restriction. However, there is no evidence of any benefit of bedrest or reduced activity during pregnancy for either of these conditions. On the contrary, there is evidence of harm, in addition to the fact that exercise is known to be beneficial in pregnancy.

The effect of position change on vital signs, back pain and vascular complications following percutaneous coronary intervention.

AIMS AND OBJECTIVES: To determine the effect of position change that is applied after percutaneous coronary intervention on vital signs, back pain and vascular complications. BACKGROUND: In order to minimise the postprocedural complications, patients are restricted to prolonged bed rest that is always accompanied by back pain and haemodynamic instability. DESIGN: Randomised-controlled quasi-experimental study. METHODS: The study sample chosen for this study included 200 patients who visited a hospital in Turkey between July 2014-November 2014. Patients were divided into two groups by randomisation. Patients in the control group (CG, n = 100) were put in a supine position, in which the head of the bed (HOB) was elevated to 15°, the patient's leg on the side of the intervention was kept straight and immobile; positional change was applied to patients in the experimental group (EG, n = 100). RESULTS: After the procedure in the EG, the systolic blood pressure (T4-T6), the rate of postprocedural vascular complications (1%) and the back pain scores were significantly lower (between T5-T6) than the CG, also, the back pain was the lowest level in the standard fowler's position in the 6th hr wherein the HOB was elevated by 45-60°. CONCLUSIONS: It was found that systolic blood pressure and back pain were at the lowest levels in the standard fowler's position in the 6th hr after the procedure when the HOB was elevated 45-60° and the result was clinically significant and the position change decreased back pain without causing any vascular complications. RELEVANCE TO CLINICAL PRACTICE: Low fowler's position was applied in which HOB was elevated 15-30° and standard fowler's position was applied in which the HOB was elevated 45-60° could be safe and applicable in patients by nurses after the procedure.

2,000 Steps/Day Does Not Fully Protect Skeletal Muscle Health in Older Adults During Bed Rest.

Physical activity in an inpatient setting is often limited to brief periods of walking. For healthy adults, public health agencies recommend a minimum of 150 min/week of moderate-intensity exercise. The authors sought to determine if meeting this activity threshold, in the absence of incidental activities of daily living, could protect skeletal muscle health during bed rest. Healthy older adults (68 ± 2 years) were randomized to 7-day bed rest with (STEP, n = 7) or without (CON, n = 10) a 2,000 steps/day intervention. Performing 2018 ± 4 steps/day did not prevent the loss of lean leg mass and had no beneficial effect on aerobic capacity, strength, or muscle fiber volume. However, the insulin response to an oral glucose challenge was preserved. Performing a block of 2,000 steps/day, in the absence of incidental activities of daily living, was insufficient to fully counter the catabolic effects of bed rest in healthy older adults.

Interventions during pregnancy to prevent preterm birth: an overview of Cochrane systematic reviews.

BACKGROUND: Preterm birth (PTB) is a major factor contributing to global rates of neonatal death and to longer-term health problems for surviving infants. Both the World Health Organization and the United Nations consider prevention of PTB as central to improving health care for pregnant women and newborn babies. Current preventative clinical strategies show varied efficacy in different populations of pregnant women, frustrating women and health providers alike, while researchers call for better understanding of the underlying mechanisms that lead to PTB. OBJECTIVES: We aimed to summarise all evidence for interventions relevant to the prevention of PTB as reported in Cochrane systematic reviews (SRs). We intended to highlight promising interventions and to identify SRs in need of an update. METHODS: We searched the Cochrane Database of Systematic Reviews (2 November 2017) with key words to capture any Cochrane SR that prespecified or reported a PTB outcome. Inclusion criteria focused on pregnant women without signs of preterm labour or ruptured amniotic membranes. We included reviews of interventions for pregnant women irrespective of their risk status. We followed standard Cochrane methods.We applied GRADE criteria to evaluate the quality of SR evidence. We assigned graphic icons to classify the effectiveness of interventions as: clear evidence of benefit; clear evidence of harm; clear evidence of no effect or equivalence; possible benefit; possible harm; or unknown benefit or harm. We defined clear evidence of benefit and clear evidence of harm to be GRADE moderate- or high-quality evidence with a confidence interval (CI) that does not cross the line of no effect. Clear evidence of no effect or equivalence is GRADE moderate- or high-quality evidence with a narrow CI crossing the line of no effect. Possible benefit and possible harm refer to GRADE low-quality evidence with a clear effect (CI does not cross the line of no effect) or GRADE moderate- or high-quality evidence with a wide CI. Unknown harm or benefit refers to GRADE low- or very low-quality evidence with a wide CI. MAIN RESULTS: We included 83 SRs; 70 had outcome data. Below we highlight key results from a subset of 36 SRs of interventions intended to prevent PTB. OUTCOME: preterm birthClear evidence of benefitFour SRs reported clear evidence of benefit to prevent specific populations of pregnant women from giving birth early, including midwife-led continuity models of care versus other models of care for all women; screening for lower genital tract infections for pregnant women less than 37 weeks' gestation and without signs of labour, bleeding or infection; and zinc supplementation for pregnant women without systemic illness. Cervical cerclage showed clear benefit for women with singleton pregnancy and high risk of PTB only.Clear evidence of harmNo included SR reported clear evidence of harm.No effect or equivalenceFor pregnant women at high risk of PTB, bedrest for women with singleton pregnancy and antibiotic prophylaxis during the second and third trimester were of no effect or equivalent to a comparator.Possible benefitFour SRs found possible benefit in: group antenatal care for all pregnant women; antibiotics for pregnant women with asymptomatic bacteriuria; pharmacological interventions for smoking cessation for pregnant women who smoke; and vitamin D supplements alone for women without pre-existing conditions such as diabetes.Possible harmOne SR reported possible harm (increased risk of PTB) with intramuscular progesterone, but this finding is only relevant to women with multiple pregnancy and high risk of PTB. Another review found possible harm with vitamin D, calcium and other minerals for pregnant women without pre-existing conditions. OUTCOME: perinatal deathClear evidence of benefitTwo SRs reported clear evidence of benefit to reduce pregnant women's risk of perinatal death: midwife-led continuity models of care for all pregnant women; and fetal and umbilical Doppler for high-risk pregnant women.Clear evidence of harmNo included SR reported clear evidence of harm.No effect or equivalenceFor pregnant women at high risk of PTB, antibiotic prophylaxis during the second and third trimester was of no effect or equivalent to a comparator.Possible benefitOne SR reported possible benefit with cervical cerclage for women with singleton pregnancy and high risk of PTB.Possible harmOne SR reported possible harm associated with a reduced schedule of antenatal visits for pregnant women at low risk of pregnancy complications; importantly, these women already received antenatal care in settings with limited resources. OUTCOMES: preterm birth and perinatal deathUnknown benefit or harmFor pregnant women at high risk of PTB for any reason including multiple pregnancy, home uterine monitoring was of unknown benefit or harm. For pregnant women at high risk due to multiple pregnancy: bedrest, prophylactic oral betamimetics, vaginal progesterone and cervical cerclage were all of unknown benefit or harm. AUTHORS' CONCLUSIONS: Implications for practiceThe overview serves as a map and guide to all current evidence relevant to PTB prevention published in the Cochrane Library. Of 70 SRs with outcome data, we identified 36 reviews of interventions with the aim of preventing PTB. Just four of these SRs had evidence of clear benefit to women, with an additional four SRs reporting possible benefit. No SR reported clear harm, which is an important finding for women and health providers alike.The overview summarises no evidence for the clinically important interventions of cervical pessary, cervical length assessment and vaginal progesterone because these Cochrane Reviews were not current. These are active areas for PTB research.The graphic icons we assigned to SR effect estimates do not constitute clinical guidance or an endorsement of specific interventions for pregnant women. It remains critical for pregnant women and their healthcare providers to carefully consider whether specific strategies to prevent PTB will be of benefit for individual women, or for specific populations of women.Implications for researchFormal consensus work is needed to establish standard language for overviews of reviews and to define the limits of their interpretation.Clinicians, researchers and funders must address the lack of evidence for interventions relevant to women at high risk of PTB due to multiple pregnancy.

Electromyographic evaluation of high-intensity elastic resistance exercises for lower extremity muscles during bed rest.

PURPOSE: Prolonged hospital bed rest after severe injury or disease leads to rapid muscle atrophy and strength loss. Therefore, the main aim of this study was to evaluate the efficacy of lower extremity strengthening exercises using elastic resistance that can be performed while lying in a hospital bed. METHODS: Using a cross-sectional design, 22 healthy individuals performed three consecutive repetitions of 14 different lower extremity exercises using elastic resistance, with a perceived intensity corresponding to 8 on the Borg CR-10 scale. Surface electromyography was measured on 13 lower extremity muscles and normalized to the maximal EMG (nEMG). Likewise, exercise satisfaction was evaluated by a questionnaire. RESULTS: All participants were able to perform all exercises without discomfort and generally rated them satisfactory. High levels of muscle activity were observed for all prime movers. For example, the "femoris muscle setting" exercise showed high levels of muscle activity for rectus femoris, vastus lateralis, and vastus medialis (79, 75, and 79% nEMG, respectively), while biceps femoris and semitendinosus were highly active during the prone knee flexion exercise with (72 and 71% nEMG, respectively) and without Kinesiology Tape (73 and 77% nEMG, respectively). CONCLUSION: High levels of muscle activity in the lower extremities can be achieved using elastic resistance exercises performed when lying in a hospital bed. Even though performed on healthy individuals, the present study has the potential to provide a reference table of exercises to select from when individualizing and progressing strengthening exercises during the early rehabilitation of bedridden individuals.

Consensus guidelines for enhanced recovery after gastrectomy: Enhanced Recovery After Surgery (ERAS®) Society recommendations.

BACKGROUND: Application of evidence-based perioperative care protocols reduces complication rates, accelerates recovery and shortens hospital stay. Presently, there are no comprehensive guidelines for perioperative care for gastrectomy. METHODS: An international working group within the Enhanced Recovery After Surgery (ERAS®) Society assembled an evidence-based comprehensive framework for optimal perioperative care for patients undergoing gastrectomy. Data were retrieved from standard databases and personal archives. Evidence and recommendations were classified according to the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system and were discussed until consensus was reached within the group. The quality of evidence was rated 'high', 'moderate', 'low' or 'very low'. Recommendations were graded as 'strong' or 'weak'. RESULTS: The available evidence has been summarized and recommendations are given for 25 items, eight of which contain procedure-specific evidence. The quality of evidence varies substantially and further research is needed for many issues to improve the strength of evidence and grade of recommendations. CONCLUSION: The present evidence-based framework provides comprehensive advice on optimal perioperative care for the patient undergoing gastrectomy and facilitates multi-institutional prospective cohort registries and adequately powered randomized trials for further research.

Maternal activity restriction in pregnancy and the prevention of preterm birth: an evidence-based review.

Activity restriction is one of the most common practices used for the prevention of preterm birth. Despite the lack of evidence to support the efficacy of activity restriction, and newer data that highlight potential harms to the mother, the intervention is still prescribed. This review of the literature describes the potential benefits, harms, and efficacy of activity restriction in the prevention of preterm birth.

The metabolic cost of an integrated exercise program performed during 14 days of bed rest.

BACKGROUND: Exercise countermeasures designed to mitigate muscle atrophy during long-duration spaceflight may not be as effective if crewmembers are in negative energy balance (energy output > energy input). This study determined the energy cost of supine exercise (resistance, interval, aerobic) during the spaceflight analogue of bed rest. METHODS: Nine subjects (eight men and one woman; 34.5 +/- 8.2 yr) completed 14 d of bed rest and concomitant exercise countermeasures. Body mass and basal metabolic rate (BMR) were assessed before and during bed rest. Exercise energy expenditure was measured during and immediately after [excess post-exercise oxygen consumption (EPOC)] each of five different exercise protocols (30-s, 2-min, and 4-min intervals, continuous aerobic, and a variety of resistance exercises) during bed rest. RESULTS: On days when resistance and continuous aerobic exercise were performed daily, energy expenditure was significantly greater (2879 +/- 280 kcal) than 2-min (2390 +/- 237 kcal), 30-s (2501 +/- 264 kcal), or 4-min (2546 +/- 264 kcal) exercise. There were no significant differences in BMR (pre-bed rest: 1649 +/- 216 kcal; week 1: 1632 +/- 174 kcal; week 2:1657 +/- 176 kcal) or body mass (pre-bed rest: 75.2 +/- 10.1 kg; post-bed rest: 75.2 +/- 9.6 kg). DISCUSSION: These findings highlight the importance of energy balance for long-duration crewmembers completing a high-intensity exercise program with multiple exercise sessions daily.

Intracranial hematoma as the cause of headache after subarachnoid anesthesia for cesarean section--a case report.

BACKGROUND: Intracranial subdural hematoma is an exceptionally rare but life-threating complication of epidural and spinal anesthesia. The diagnosis is rather difficult because the initial symptoms mimic post-dural puncture headache. CASE REPORT: A 33-year-old primipara was admitted to the hospital at 38 weeks gestation for a cesarean section due to premature rupture of membranes and meconium stained amniotic fluid. During the procedure a single puncture between L2 and L3 vertebrae was made with the use of a 26-gauge, pencil-point needle. The amount of 2.8 ml of analgesic solution was administered in order to obtain subarachnoid analgesia at the level of Th4 and Th5 vertebrae. Postpartum recovery was uneventful for the first two days. On the third day the patient developed strong headache in the forehead area and tinnitus. An anesthesiologist diagnosed post-dural puncture headache (PDPH). The patient received 1 g of Paracetamol every 6 hours intravenously together with 3000 ml of crystalloid solution for 24 hours. As a result, the patient recovered and was discharged home with her infant. Five days later the patient presented at the neurology clinic because of strong and chronic temporal lobe headache. No other complaints were reported. Upon admission, the patient had a head CT followed by an MRI examination, which revealed cranial hematomas localized bilaterally in the area of the frontal, temporal and parietal lobes, spreading from the cranial vault to the skull base. The width of the hematomas was: 3-4 mm on the left and 5-6 mm on the right side. Hematomas infiltrated the anterior part of the medial longitudinal fissure. Magnetic resonance angiography showed normal images of the arteries, veins, and the dural venous sinuses. No vascular malformations, which may be a source of intracranial hemorrhage, were found. Other tests showed normal results. Patient condition during hospitalization was stable. Conservative treatment was implemented, i.e. fluids administered intravenously anti-edematous drugs, analgesic medications and bed rest. All pain complaints subsided and a control CT scan showed that hematomas evolved as expected i.e. their HU density decreased. About 6 weeks later the patient had a CT head scan, performed in outpatient settings, which showed complete absorption of extravasated blood. CONCLUSION: The presented case shows headaches in obstetric patients require thorough diagnostic examinations and appropriate management. In addition to the most typical PDPH, it may be the first sign of life-threatening intracranial pathology

Early versus delayed mobilisation for aneurysmal subarachnoid haemorrhage.

BACKGROUND: Rebleeding is an important cause of death and disability in patients with aneurysmal subarachnoid haemorrhage (SAH). In order to prevent rebleeding, the preferred strategy is aneurysm ablation (removal) as early as possible. However, in clinical practice some patients are not suitable for surgical treatment, or prefer conservative treatments. In some countries, therefore, total bedrest for four to six weeks has been considered one of the basic interventions to avoid rebleeding. However, the influence of bedrest on outcome in patients with SAH is not well known. OBJECTIVES: To establish whether early mobilisation (less than four weeks after symptom onset) compared with delayed mobilisation (defined as patients staying in bed for at least four weeks after symptom onset) in patients with aneurysmal subarachnoid haemorrhage (SAH), who have not had or could not have any surgical treatment for the aneurysm, will increase the proportion of deaths from rebleeding. SEARCH METHODS: We searched the Cochrane Stroke Group Trials Register (May 2012), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 6), the Chinese Stroke Trials Register (May 2012), MEDLINE (1950 to June 2012), EMBASE (1980 to June 2012), Web of Science Conference Proceedings (1990 to May 2012), CINAHL (1982 to June 2012), AMED (1985 to June 2012), PEDro (May 2012), REHABDATA (May 2012) and CIRRIE Database of International Rehabilitation Research (May 2012). In addition, we searched five Chinese databases, ongoing trials registers and relevant reference lists. SELECTION CRITERIA: We planned to include randomised controlled trials (RCTs) comparing early mobilisation (within four weeks after symptom onset) with delayed mobilisation (after four weeks). DATA COLLECTION AND ANALYSIS: Two review authors independently selected trials for inclusion and exclusion. We resolved disagreements by discussion. MAIN RESULTS: In the absence of any suitable RCTs addressing this topic, we were unable to perform a meta-analysis. Data from recent observational studies suggested the period of greatest risk for rebleeding occurs more frequently in the early period, especially within 24 hours of the initial SAH. The impact of bedrest on aneurysm care should be clarified. AUTHORS' CONCLUSIONS: There are no RCTs or controlled trials that provide evidence for, or against, staying in bed for at least four weeks after symptom onset in patients with aneurysmal SAH, who have not had, or could not have, surgical treatment for the aneurysm. Treatment strategies to reduce the risk of rebleeding in SAH patients before aneurysm ablation, or in those not suitable for surgical treatment, or who prefer conservative treatments, deserve attention.

Turning and repositioning the critically ill patient with hemodynamic instability: a literature review and consensus recommendations.

In the critical care population, heart rate and rhythm, blood pressure, respiratory rate, and oxygen saturation are monitored continuously, providing immediate feedback regarding any changes in patient status. Hemodynamic instability is a term commonly used by clinicians to describe labile changes in cardiopulmonary status, although this term is poorly defined in the literature. The clinician's perception of hemodynamic instability may cause a delay or omission in turning, repositioning, and other interventions to advance patient mobility and may contribute to pressure ulcer formation. The intensive care unit's practice culture and individual clinician perceptions regarding hemodynamic instability may lead to staff not turning patients out of fear that they are "too unstable to turn." This article provides a discussion of the link between pressure ulcers and immobility, provides a review of current literature on progressive mobility and hemodynamic instability, and presents the results of a critical care consensus panel on safe and effective turning of critical care patients.

Adding Brief Pain Science or Ergonomics Messages to Guideline Advice Did Not Increase Feelings of Reassurance in People With Acute Low Back Pain: A Randomized Experiment.

OBJECTIVE: To investigate the effects of adding pain science or ergonomics messages to guideline advice on feelings of reassurance and management intentions among people with acute low back pain (LBP). DESIGN: Three-arm parallel-group randomized experiment. METHODS: We recruited people with acute LBP (pain for ≤6 weeks) to participate in an online experiment. Participants were randomized at a 1:1:1 ratio to one of three groups: guideline advice alone or guideline advice with the addition of brief pain science or ergonomics messages. The intervention was delivered via prerecorded videos in all 3 groups. Coprimary outcomes were reassurance that (1) no serious condition is causing LBP and (2) continuing with daily activities is safe. Secondary outcomes were perceived risk of developing chronic pain, management intentions (bed rest, see a health professional, see a specialist, and imaging), credibility, and relevance of the advice in addressing the participant's concerns. RESULTS: Two thousand two hundred ninety-seven responses (99.3% of 2,313 randomized) were analyzed. Adding brief pain science or ergonomics messages to guideline advice did not change reassurance that LBP was not caused by serious disease. The addition of ergonomics advice provided worse reassurance that it is safe to continue with daily activities compared to guideline advice (mean difference [MD], -0.33; 95% CI: 0.13, 0.53). There was no difference between groups on management intentions. CONCLUSION: Adding pain science or ergonomics messages to guideline advice did not increase reassurance or change management intentions in people with acute LBP. Ergonomics messages may lead to reduced feelings of reassurance. J Orthop Sports Phys Ther 2023;53(12)1-11. Epub 26 September 2023. doi:10.2519/jospt.2023.12090.

Prolonged bed rest as adjuvant therapy after complex reconstructive spine surgery.

BACKGROUND: The benefits of postoperative mobilization include decreased incidence of pulmonary complications, pressure ulcers, and progression of deep vein thrombosis. However, the complexity of certain spinal reconstructions and the patient's physiologic condition may preclude the possibility of early mobilization. Prolonged bed rest after spine surgery is controversial. QUESTIONS/PURPOSES: We evaluated the efficacy of prolonged bed rest after complex spine surgery to determine (1) patient characteristics that led to prescribing bed rest, (2) clinical and radiographic outcomes, (3) complications, and (4) estimated direct costs. METHODS: We retrospectively reviewed all 11 patients (median age, 50 years) who underwent complex spine surgery followed by prolonged bed rest between 2005 and 2010. All patients were deemed at high risk for developing pseudarthrosis or instrumentation failure without postoperative bed rest. One patient died of complications related to pulmonary tuberculosis at 4 months. The patients averaged 3 months of bed rest. Minimum followup was 24 months (median, 30 months; range, 4-52 months). RESULTS: All patients had (1) tenuous or limited fixation after correction of severe deformity, (2) previously failed spine reconstruction after early mobilization, or (3) limited treatment options if failure occurred again. No patient experienced pseudarthrosis, failure of instrumentation, thromboembolic disease, pressure ulcers, or pneumonia. One patient had a delayed union and one developed late urosepsis. The median cost of skilled nursing facilities during the period of bed rest was $16,702, while the median cost of home health nursing was $5712. CONCLUSIONS: For patients with contraindications to early postoperative mobilization, prolonged bed rest may be useful to minimize the risk of complications that can occur with mobilization. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.