Rehabilitative of COVID-19 patients with acute lower extremity Ischemia and amputation.

OBJECTIVE: To evaluate the clinical characteristics and rehabilitation management of patients who undergo amputation for COVID-19-associated coagulopathy. METHODS: Clinical and laboratory data for 3 patients were analysed and their rehabilitative management discussed. RESULTS: The medical records of 3 patients who had undergone amputation due to acute lower extremity ischaemia and who were provided with rehabilitation in our COVID-19 unit were reviewed. CONCLUSION: Coagulation changes related to SARS-CoV-2 may complicate recovery from this devastating disease. The rehabilitation management of amputated patients for COVID-19 acute lower extremity ischaemia is based on a multilevel approach for clinical, functional, nutritional and neuropsychological needs. Based on this limited experience, a dedicated programme for this specific group of patients seems advantageous to warrant the best functional outcome and quality of life.

Positive Balance Recovery in Ischemic Post-Stroke Patients with Delayed Access to Physical Therapy.

BACKGROUND: Since patient's prognosis after stroke depends on its severity, brain location, and type early intervention is strongly recommended. OBJECTIVE: We aimed to determine whether it is still possible to improve balance in chronic patients, who suffered Intracerebral Hemorrhagic Strokes (ICHS) or Ischemic Strokes (IS), after later intervention. METHODS: 34 patients who had unilateral ICHS or IS and involved the motor cortex or sub-cortical areas took part in the study. The patients underwent clinical balance evaluation (using the Berg Balance Scale) and posturographic assessment (with a capacitive pressure platform) at the time of admission to the physiotherapy and at the end of the study. The physiotherapy intervention consisted of 20 sessions of 60 minutes carried out 3 times per week, following standard protocols: stretching; passive range of motion (ROM); active assistive ROM; active ROM; resistance training; coordination and balance activities while sitting and standing, and Large-muscle activities such as walking, treadmill, stationary cycle, combined arm-leg ergometry, arm ergometry, seated stepper and circuit training. RESULTS: In the posturographic assessment, the IS group had significant lower amplitude of center of pressure (COP) anteroposterior displacement, after physical therapy intervention. Also, the 95% confidence ellipse area of the COP and the total COP displacement showed significant interaction between the subtype of stroke and the assessment period, meaning the IS group improved their balance after treatment on the contrary of ICHS. The structural analysis of the COP reinforced these results. On the other hand, no difference was observed in the clinical scale, between the assessment periods, for any subtype of stroke. CONCLUSION: Only IS patients have shown balance improvements after conventional intervention. COP measurements are more sensible to assess balance in chronic patients than Berg Balance Scale.

Referral from vascular surgery to cardiovascular rehabilitation and related outcomes in patients with peripheral arterial disease: the THINKPAD-RELOADED survey.

The utilization of cardiovascular rehabilitation (CR) programmes in patients with Lower Extremity Peripheral Artery Disease (LEPAD) is generally poor, with limited evidence of current policies for referral. The aim of the study was to evaluate, within a cohesive network of CR and vascular surgery facilities with facilitated referral process, the clinical characteristic of LEPAD patients referred to CR and related outcomes, as compared to patients not referred. The present is an observational prospective study of consecutive patients recruited at vascular surgery facilities. Out of 329 patients observed, the average referral rate to CR was 34% (28% and 39% in patients with and without recent peripheral revascularization, p<0.05). LEPAD patients entering the CR programme were similar to those who did not according to sex, age, the vascular surgery setting of evaluation, and localization of arterial lesions. Patients with moderate intermittent claudication and patients with acute limb ischemia as index event were more represented among those who attended CR (41% vs 21% and 9% vs 2% respectively, p<0.05). Patients referred to CR had five times more episodes of acute coronary syndrome and heart failure as complication of the index event. The cardiovascular risk profile (obesity 29.5% vs 11%, p<0.05; hypercholesterolemia 80% vs 61%, p<0.05) was much worse in LEPAD patients referred to CR, but conversely, they better achieved secondary prevention targets, particularly for blood pressure control (97% vs 57%, p<0.05). All-cause 2-year mortality in the whole patients' population was 6%. Patients entering the CR programme displayed less events (13.5% vs 37.7%, p<0.05), mainly death (3.1% vs 11.3%, p<0.05) and limb-related events (4.2% vs 15.2%, p<0.05). The results of our study suggest that when a cohesive network of vascular surgery and CR facilities becomes available, the referral rate to rehabilitation may increase up to one third of eligible patients. Patients with higher comorbidity and cardiovascular risk seem to have priority in the referral process, nevertheless those with peripheral revascularization are still underestimated. Entering CR may ensure better cardiovascular risk profile and cardiovascular prognosis in LEPAD patients, and consequently the systematic adoption of this care model needs to be strongly recommended and facilitated.

Fisioterapia intra-hospitalar para pacientes com isquemia crítica de membro inferior: consenso de especialistas / Fisioterapia intrahospitalaria para pacientes con isquemia crítica de miembro inferior: consenso de especialistas / Intra-hospital physical therapy for patients with critical lower limb ischaemia: an expert consensus

RESUMO A isquemia crítica de membro inferior (ICMI) gera impacto nos sistemas de saúde, na qualidade de vida e funcionalidade dos indivíduos diagnosticados. Entretanto, há pouca evidência científica que permita fundamentar a intervenção fisioterapêutica para pacientes internados por ICMI. O objetivo desse estudo foi elaborar um consenso de especialistas sobre a fisioterapia intra-hospitalar para pacientes com ICMI. Para tal, foi utilizado o método Delphi. Um painel de especialistas foi formado por 18 fisioterapeutas que representavam 85,7% da equipe de um hospital de referência em cirurgia vascular. Foram consideradas, para o consenso, as respostas com valor mínimo de concordância de 70% e média ou mediana ≥3,1 na escala Likert. Os questionários abordaram itens da avaliação, objetivos e condutas fisioterapêuticas nas fases pré e pós-cirurgia de revascularização. Definiram-se como itens essenciais a avaliação de sintomas, função cognitiva, musculoesquelética e cardiorrespiratória. Controle da dor, redução de edemas, ganho de amplitude de movimento, deambulação e educação em saúde são objetivos no pré-operatório e o ganho de força muscular na fase pós-operatória. Exercícios passivo, assistido, ativo livre e circulatório, incluindo os membros superiores, estão indicados antes e após as cirurgias. Educação em saúde e deambulação com redução de peso em área de lesão plantar são essenciais em todo o período de internação. A eletroanalgesia foi preconizada no pré-operatório e a elevação do membro inferior e exercícios resistidos no pós-operatório.

RESUMEN La isquemia crítica de miembro inferior (ICMI) afecta a los sistemas de salud y la calidad de vida y funcionalidad de los individuos diagnosticados. Sin embargo, hay poca evidencia científica que fundamente la intervención fisioterapéutica para pacientes internados por ICMI. El objetivo de este estudio fue elaborar un consenso de especialistas sobre la fisioterapia intrahospitalaria para pacientes con ICMI. Para ello, se utilizó el método Delphi. Se formó un panel de expertos con 18 fisioterapeutas que representaban el 85,7% del equipo de un hospital de referencia en cirugía vascular. Se consideraron, para el consenso, las respuestas con un valor mínimo de concordancia del 70% y media o mediana ≥3,1 en la escala Likert. Los cuestionarios abordaron ítems de evaluación, objetivos y conductas fisioterapéuticas en las fases pre y poscirugía de revascularización. Se definieron como elementos esenciales la evaluación de síntomas y las funciones cognitiva, musculoesquelética y cardiorrespiratoria. En el preoperatorio, control del dolor, reducción de edemas, ganancia de amplitud de movimiento, deambulación y educación en salud son los objetivos; en la fase posoperatoria, la ganancia de fuerza muscular. Los ejercicios pasivos, asistidos, activos libres y circulatorios, incluidos los miembros superiores, se indican antes y después de las cirugías. La educación en salud y la deambulación con reducción de peso en el área de lesión plantar son esenciales en todo el período de internación. La electroanalgesia fue preconizada en el preoperatorio; y, en el postoperatorio, elevación del miembro inferior y ejercicios resistidos.

ABSTRACT Critical limb ischemia (CLI) is a disease with a great burden for the healthcare system, patient's functionality and quality of life. However, there is little evidence to guide intrahospital physical therapy programs for patients with CLI. Thus, this study aimed to provide an expert consensus on intrahospital physiotherapeutic care for CLI patients. An expert panel was made up with 18 experienced physical therapists, which represented 85.7% of physical therapists from a reference vascular surgery team in a university hospital. The Delphi method was used to produce a consensus, considering a minimum agreement of 70% and a mean or median score in the Likert scale ≥3.1. The questionnaires included items related to assessment, goals and physiotherapeutic interventions prior and after revascularization. A consensus was reached on assessing symptoms, cognitive, articular, musculoskeletal and cardiorespiratory functions. Pain control, edema drainage, range of motion gain, walking incentive and health education are goals in the pre-operatory and the muscular strengthening in postoperatory phase. In both phases there was a consensus on the use of passive, active-assisted and active exercises, including upper limb exercises. Walking and therapeutic education are essential during the hospitalization period with offloading practices in area of plantar ulcer. Electroanalgesia should be used in preoperative phase and resisted exercises and lower limb elevation at postoperatory.

The success of salvage procedures for failing digital replants: A retrospective cohort study.

BACKGROUND: The success of salvage procedures for failing digital replants (FR) is poorly documented. We sought to evaluate the success of salvage procedures for FR and factors contributing to successes and failures of replants. METHODS: Adult patients who presented to our center between January 1, 2000 and December 31, 2015, suffered ≥1 digital amputation(s), and underwent digital replantation were included. Preoperative, perioperative, and postoperative details were recorded. Digits were monitored postoperatively via nursing and physician assessments. The presumed reason for failure, details, and outcomes of salvage attempts were recorded for FR. Length of hospital stay and complications were also recorded. RESULTS: Fifty-two patients and 83 digits were included. Fifty-two digits (63%) were compromised (arterial ischemia in 15 digits; venous congestion in 37 digits) and 48 digits had salvage therapy. Twenty-one FR (44%) were salvaged via operative (1 of 2; 50%), nonoperative (19 of 43; 44%), and combined (1 of 3; 33%) therapies. FR patients were more likely than those with successful replants to receive a blood transfusion (52 vs. 23%; p = .009) with more transfused units (3.45 ± 3.30 vs. 0.86 ± 0.95; p = .001). Length of stay was prolonged for FR patients (9 [range: 2-22] vs. 7 [range: 3-19] days; p = .039). Ultimately, 59% (49 of 83) of replants were successful, where 25% (21 of 83) were successfully salvaged. CONCLUSION: Nonoperative and operative salvage therapies improve the rate of replant survival. We suggest close postoperative monitoring of all replants and active salvage interventions for compromised replants in the postoperative period.

[Psychological rehabilitation in patients with ischemic heart disease in the last 30 years].

Cardiological rehabilitation is one of the basic methods used in the treatment of cardiovascular diseases including ischemic heart disease. Complex cardiological rehabilitation consists of clinical assessment, pharmacotherapy, kinesitherapy, psychological rehabilitation, assessment of cardiovascular risk factors prevalence, lifestyle modification and health education of patients. The paper presents methods of psychological therapy applied at different stages of psychological rehabilitation in traditional clinical procedure in patients with ischemic heart disease. In the mid 90-ties of the 20th century new, invasive diagnostic and treatment methods of cardiovascular diseases were introduced. Along with application of modern methods of invasive treatment methods of psychological rehabilitation changed towards crisis intervention.

Fucoidan improves bioactivity and vasculogenic potential of mesenchymal stem cells in murine hind limb ischemia associated with chronic kidney disease.

Chronic kidney disease (CKD) is a significant risk factor for cardiovascular and peripheral vascular disease. Although mesenchymal stem cell (MSC)-based therapy is a promising strategy for treatment of ischemic diseases associated with CKD, the associated pathophysiological conditions lead to low survival and proliferation of transplanted MSCs. To address these limitations, we investigated the effects of fucoidan, a sulfated polysaccharide, on the bioactivity of adipose tissue-derived MSCs and the potential of fucoidan-treated MSCs to improve neovascularization in ischemic tissues of CKD mice. Treatment of MSCs with fucoidan increased their proliferative potential and the expression of cell cycle-associated proteins, such as cyclin E, cyclin dependent kinase (CDK) 2, cyclin D1, and CDK4, via focal adhesion kinase and the phosphatidylinositol-4,5-bisphosphate 3-kinase-Akt axis. Moreover, fucoidan enhanced the immunomodulatory activity of MSCs through the ERK-IDO-1 signal cascade. Fucoidan was found to augment the proliferation, incorporation, and endothelial differentiation of transplanted MSCs at ischemic sites in CKD mice hind limbs. In addition, transplantation of fucoidan-treated MSCs enhanced the ratio of blood flow and limb salvage in CKD mice with hind limb ischemia. To our knowledge, our findings are the first to reveal that fucoidan enhances the bioactivity of MSCs and improves their neovascularization in ischemic injured tissues of CKD. In conclusion, fucoidan-treated MSCs may provide an important pathway toward therapeutic neovascularization in patients with CKD.

Changes in flow-mediated dilatation in patients with femoropopliteal occlusion receiving conservative and invasive treatment.

BACKGROUND: Although the beneficial effect of revascularisation on reduction of local clinical ischaemic symptoms has been well established, its effect on systemic vascular endothelial function has not been fully explained yet. AIM: To determine changes in endothelium-dependent flow-mediated dilatation in patients with unilateral femoropopliteal occlusion receiving medical and surgical treatment. METHODS: Seventy-nine patients with symptomatic atherosclerotic ischaemia of lower extremities, treated with endovascular procedures, with femoropopliteal graft, or receiving conservative treatment (21-day controlled treadmill training) were enrolled in the study. Ankle brachial pressure index (ABPI), skin blood flow on the feet, and flow-mediated dilatation (FMD) of brachial arteries were measured in each patient at baseline and after 90 days of follow-up. RESULTS: The ABPI, vasomotion in the myogenic frequency band, and FMD increased significantly in surgical patients. In patients after femoropopliteal bypass a significant increase of vasomotion in the endothelial frequency band was also observed. In patients receiving conservative treatment (treadmill training), vasomotion in the myogenic frequency band increased whereas the FMD remained unchanged. CONCLUSIONS: It seems that surgical treatment may contribute to reducing the risk of cardiovascular complications in patients with advanced peripheral artery disease, as a result of improving the systemic vascular endothelial function. Limiting treatment to just treadmill training increases pain-free walking distance but does not improve systemic vascular endothelial function.

Lower limb ischaemia in patients with diabetic foot ulcers and gangrene: recognition, anatomic patterns and revascularization strategies.

The confluence of several chronic conditions--in particular ageing, peripheral artery disease, diabetes, and chronic kidney disease--has created a global wave of lower limbs at risk for major amputation. While frequently asymptomatic or not lifestyle limiting, at least 1% of the population has peripheral artery disease of sufficient severity to be limb threatening. To avoid the critical error of failing to diagnose ischaemia, all patients with diabetic foot ulcers and gangrene should routinely undergo physiologic evaluation of foot perfusion. Ankle brachial index is useful when measurable, but may be falsely elevated or not obtainable in as many as 30% of patients with diabetic foot ulcers primarily because of medial calcinosis. Toe pressures and skin perfusion pressures are applicable to such patients.

The Effects of Limb Elevation on Muscle Oxygen Saturation: A Near-Infrared Spectroscopy Study in Humans.

BACKGROUND: Orthopaedic and rehabilitation physicians often instruct patients to elevate a traumatized or postoperative lower extremity. Elevation is thought to improve patient comfort, as well as decrease swelling, wound complications, and the risk of compartment syndrome. Elevating a limb with increased compartment pressures, however, has been shown to reduce perfusion pressure and contribute to tissue ischemia. This investigation aims to advance our understanding of the tissue effects of limb elevation using a healthy patient model. OBJECTIVE: To quantify the effects of elevation, experimentally induced ischemia, and immobilization on muscle oxygen saturation in the human leg using near-infrared spectroscopy (NIRS). DESIGN: Experimental crossover study. SETTING: Orthopaedic Surgery research laboratory, Stanford Hospitals & Clinics. PATIENTS FOR PARTICIPATION: Twenty-six healthy volunteers. METHODS: Using transcutaneous sensors, we measured muscle oxygen saturation of the anterior compartment of the left (control) leg at 0, 15, and 30 cm of elevation relative to the heart using NIRS. A standardized short leg splint and a thigh tourniquet inflated to 50 mmHg were then applied to the right (experimental) leg to simulate a traumatized state. NIRS measurements were then repeated, again at 0, 15, and 30 cm of elevation. Muscle oxygen saturation values at various degrees of elevation of the control and experimental limb were then compared and analyzed by the use of a crossover study design and mixed-effects regression. MAIN OUTCOME MEASUREMENTS: Muscle oxygen saturation at varying levels of elevation in both the (1) control leg and (2) experimental leg in a simulated traumatic state. RESULTS: Male (18) males and female (8) patients between 22 and 62 years of age (mean 29.8 years) were enrolled. Mean regional muscle oxygen saturation (rSO2) of the control limbs at 0, 15 and, 30 cm of elevation were 74.2%, 72.5%, and 70.6%, respectively, whereas mean rSO2 of the experimental limbs were 66.3%, 65.0%, and 63.3%. A statistically significant decrease of rSO2 was observed (mean 7.65%) in the experimental limbs compared with the control limbs. As elevation increased, there was a statistically significant decrease in rSO2 of 0.12% per centimeter of elevation. Elevation did not decrease the rSO2 in the experimental limb to a greater degree than in the control limb. CONCLUSION: Increasing levels of elevation in a human limb results in progressively compromised muscle oxygen saturation as measured by NIR.

Rehabilitation Outcomes: Ischemic versus Hemorrhagic Strokes.

Background. Ischemic and hemorrhagic strokes have different pathophysiologies and possibly different long-term cerebral and functional implications. Hemorrhagic strokes expose the brain to irritating effects of blood and ischemic strokes reflect localized or diffuse cerebral vascular pathology. Methods. Participants were individuals who suffered either an ischemic (n = 172) or hemorrhagic stroke (n = 112) within the past six months and were involved in a postacute neurorehabilitation program. Participants completed three months of postacute neurorehabilitation and the Mayo Portland Adaptability Inventory-4 (MPAI-4) at admission and discharge. Admission MPAI-4 scores and level of functioning were comparable. Results. Group ANOVA comparisons show no significant group differences at admission or discharge or difference in change scores. Both groups showed considerably reduced levels of productivity/employment after discharge as compared to preinjury levels. Conclusions. Though the pathophysiology of these types of strokes is different, both ultimately result in ischemic injuries, possibly accounting for lack of findings of differences between groups. In the present study, participants in both groups experienced similar functional levels across all three MPAI-4 domains both at admission and discharge. Limitations of this study include a highly educated sample and few outcome measures.

Red wine polyphenol compounds favor neovascularisation through estrogen receptor α-independent mechanism in mice.

Red wine polyphenol compounds (RWPC) exert paradoxical effects depending on the dose on post-ischemic neovascularisation. Low dose RWPC (0.2 mg/kg/day) is pro-angiogenic, whereas high dose (20 mg/kg/day) is anti-angiogenic. We recently reported that the endothelial effect of RWPC is mediated through the activation of a redox-sensitive pathway, mitochondrial biogenesis and the activation of α isoform of the estrogen receptor (ERα). Here, we investigated the implication of ERα on angiogenic properties of RWPC. Using ovariectomized mice lacking ERα treated with high dose of RWPC after hindlimb ischemia, we examined blood flow reperfusion, vascular density, nitric oxide (NO) production, expression and activation of proteins involved in angiogenic process and muscle energy sensing network. As expected, high dose of RWPC treatment reduced both blood flow and vascular density in muscles of mice expressing ERα. These effects were associated with reduced NO production resulting from diminished activity of eNOS. In the absence of RWPC, ERα deficient mice showed a reduced neo-vascularisation associated with a decreased NO production. Surprisingly in mice lacking ERα, high dose of RWPC increased blood flow and capillary density in conjunction with increased NO pathway and production as well as VEGF expression. Of particular interest is the activation of Sirt-1, AMPKα and PGC-1α/ß axis in ischemic hindlimb from both strains. Altogether, the results highlight a pro-angiogenic property of RWPC via an ERα-independent mechanism that is associated with an up-regulation of energy sensing network. This study brings a corner stone of a novel pathway for RWPC to correct cardiovascular diseases associated with failed neovascularisation.

Gender-related differences in critical limb ischemia due to peripheral arterial occlusive disease / Diferenças entre os gêneros em pacientes com isquemia critica por doenca arterial obstrutiva periferica

BACKGROUND: Mortality from cardiovascular disease has declined among men and increased among North American women. Recent studies have revealed differences between genders in the epidemiology of atherosclerotic disease. OBJECTIVE: To study possible differences between male and female patients with critical limb ischemia (CLI) according to risk factors of atherosclerosis and clinical characteristics of lower limbs with peripheral arterial occlusive disease (PAOD). METHODS: The study included 171 male and female patients treated for CLI due to infrainguinal PAOD and compared clinical characteristics (Rutherford category and PAOD territory), risk factors for atherosclerosis (diabetes, age, smoking and hypertension) and number of opacified arteries on digital angiograms of the leg. The EPI-INFO software was used for statistical analysis, and the level of significance was set at p<0.05. RESULTS: Mean age was 70 years, and 88 patients were men (52%). For most patients (both genders), Rutherford category was 5 (82 % of men and 70% of women; p=0.16). The group of women had higher mean age (73 vs. 67 years; p=0.0002) and greater prevalence of diabetes (66% vs. 45%; p=0.003) and hypertension (90% vs. 56%; p=0.0000001). Among men, the prevalence of smoking was higher (76% vs. 53%; p=0.0008). The analysis of digital angiograms revealed that opacification of only one artery in the leg was found for 74% of women (vs. 50% of men). CONCLUSION: The prevalence of risk factors for atherosclerosis and the characteristics of PAOD are different between male and female patients with CLI. .

CONTEXTO: A mortalidade por doença cardiovascular vem declinando entre os homens e aumentando entre as mulheres norte-americanas. Pesquisas mostraram diferenças relacionadas ao gênero na epidemiologia da doença aterosclerótica. OBJETIVO: Estudar possíveis diferenças entre pacientes com isquemia crítica por doença arterial obstrutiva periférica (DAOP), de ambos os gêneros, em relação à presença de fatores de risco para a aterosclerose e características da DAOP infrainguinal. MÉTODOS: Foram incluídos 171 doentes internados com isquemia crítica por DAOP infrainguinal. Estudamos comparativamente, entre homens e mulheres, as características clínicas (Classificação de Rutherford e território da DAOP), a presença de fatores de risco para a aterosclerose (diabetes, idade, tabagismo e hipertensão arterial) e o número de artérias com alguma opacificação nas angiografias digitais da perna. A análise estatística foi realizada pelo EPI-INFO. Considerou-se significante p <0,05. RESULTADOS: Dentre os 171 casos, a média de idade foi 70 anos, sendo 88 doentes do gênero masculino (52%). A maioria dos pacientes, de ambos os gêneros, era Categoria 5 da Classificação de Rutherford (82% dos homens e 70% das mulheres/ p =0,16). O gênero feminino apresentou média de idade mais avançada (73 VS 67 anos/ p =0,0002), maior prevalência de diabetes (66% VS 45%/ p =0,003) e de HAS (90% VS 56%/ p =0,0000001). Os homens mostraram maior prevalência de tabagismo (76% VS 53%/ p =0,0008). Nas arteriografias, 74% das mulheres (VS 50% homens) apresentaram opacificação de apenas uma artéria na perna CONCLUSÃO: O estudo mostrou que existe diferença entre homens e mulheres com isquemia crítica em relação à ...

Calidad de vida en pacientes con isquemia crónica de miembros inferiores tratados con células madre adultas / Quality of life in patients with chronic lower limb ischemia treated with adult stem cells

Se hizo una evaluación de la calidad de vida en 45 pacientes mayores de 60 años con isquemia arterial crónica de miembros inferiores; de ellos, 34 con isquemia severa y 11 con pie diabético isquémico, también con lesiones severas. A todos se les habían implantado en el miembro inferior afectado, células mononucleares derivadas de la médula ósea movilizadas a la sangre periférica con factor estimulador de colonias de granulocitos. Para la evaluación de la calidad de vida se seleccionó el cuestionario SF-36, que centra su contenido en 2 áreas: el estado funcional y el bienestar emocional. En todos los casos se manifestó una mala calidad de vida preimplante. La mejoría fue evidente a partir del sexto mes después de la terapia celular. Los casos con un año de evolución habían logrado una buena calidad de vida. La mayor parte de los pacientes que evolucionaron satisfactoriamente pudieron incorporarse a las actividades sociales y laborales, lo que con anterioridad no les era posible

An assessment of the quality of life in 45 patients older than 60 years with chronic arterial ischemia of the lower limbs was conducted. Out of them, 34 had severe ischemia, and 11 had ischemic diabetic foot, as well as severe injuries. All had been implanted mononuclear cells in the affected lower limb, which derived from the bone marrow, and mobilized to the peripheral blood with granulocyte colony stimulating factor. For assessing quality of life, SF-36 questionnaire was selected, which focuses its content on two areas: functional status and emotional well being. All cases showed poor quality of life before implantation. Improvement was evident on the sixth month after cell therapy. Cases with a year of evolution had achieved good quality of life. Most of the patients, who had successful outcomes, could join social activities and employment, which was previously not possible

Danish heart patients' participation in and experience with rehabilitation.

AIM: This study investigated the proportion of Danish patients in cardiac therapy for ischaemic heart disease who participated in cardiac rehabilitation. The study examined differences in patients' participation in and experience and satisfaction with cardiac rehabilitation. METHODS: Data were obtained from a postal questionnaire in a representative sample of patients in therapy for an ischaemic heart disease. Response data were tabulated and analysed by logistic regression. RESULTS: 3% of the patients participated in a complete rehabilitation programme according to Danish standards, 47% of the patients participated in a partial rehabilitation programme, and additionally 32% of the patients participated in a very limited rehabilitation programme. The number of patients participating in a complete rehabilitation programme was low due to the fact that only few patients (and their relatives) received psychological support. The factors living alone and low education are associated with low participation and in particular with receiving psychological support. Elderly (≥50 years) and male patients showed higher satisfaction scores. Patients receiving psychosocial elements in their rehabilitation programme reported higher satisfaction with their rehabilitation. CONCLUSIONS: Few Danish patients with ischaemic heart disease participate in a complete rehabilitation programme mainly due to psychosocial elements not yet being an integral part of cardiac rehabilitation in Denmark. There is a need to differentiate and tailor cardiac rehabilitation to different patient segments, e.g. by gender and age.

Efeito da cinesioterapia na lesão isquêmica e reperfusão em ratos / Effects of kinesiotherapy in ischemic lesion and reperfusion in rats

OBJETIVO: Verificar o efeito da cinesioterapia na funcionalidade do membro pélvico de ratos após lesão isquêmica e reperfusão. MÉTODOS: Foram utilizados 10 ratos, divididos em dois grupos, GI (controle) e GII (cinesioterapia). Todos os animais foram submetidos à isquemia por um período de três horas, seguido de reperfusão tecidual. No Grupo GII foi realizado cinesioterapia sistêmica (natação) não resistida em três sessões semanais de 50 minutos durante quatro semanas, enquanto que no grupo GI os animais permaneceram em repouso. A análise funcional do comportamento motor foi realizada semanalmente. Posteriormente, os animais foram mortos e retirados os músculos sóleo, gastrocnêmio e nervo ciático para análise histopatológica. RESULTADOS: Houve uma recuperação significativa do comportamento motor com o tratamento cinesioterapêutico ao longo das quatro semanas de tratamento. No entanto, na avaliação histológica os tecidos não mostraram alterações morfológicas de lesão e reparação celular. CONCLUSÃO: Não foi possível afirmar que o exercício mostrou-se eficiente na reparação celular, pois, tanto no grupo controle como no experimental, não apresentou diferença histológica. Por outro lado, a cinesioterapia sistêmica apresentou um efeito benéfico na reabilitação funcional após isquemia e reperfusão. Nível de Evidência III, Estudo Caso-Controle.

OBJECTIVE: To investigate the effect of kinesiotherapy on the functionality of the pelvic limb of rats after ischemic and reperfusion injury. METHODS: 10 rats were divided into two groups, GI (control) and GII (kinesiotherapy). All the animals underwent ischemia for a period of three hours, followed by tissue reperfusion. In Group GII, non-resistive systemic kinesiotherapy was performed (swimming) in three weekly sessions of 50 minutes, over a period of four weeks, while the GI animals remained at rest. Functional analysis of motor behavior was evaluated weekly. The animals were then sacrificed, and the soleus, gastrocnemius and sciatic nerve removed for histopathological analysis. RESULTS: There was a significant recovery of motor behavior with kinesiotherapeutic treatment during the four weeks of treatment. However, the histological tissues showed no morphological changes of cell injury and repair. CONCLUSION: It was not possible to affirm that the exercise was effective in cell repair, because neither of the groups (control and experimental) showed any histological difference. On the other hand, systemic kinesiotherapy showed a beneficial effect on functional rehabilitation after ischemia and reperfusion. Level of evidence III, Case-Control Study.

Improving angiogenesis and muscle performance in the ischemic limb model by physiological ischemic training in rabbits.

OBJECTIVE: The aim of this study was to test the effects of physiologic ischemic training on the performance of skeletal muscle in a pathologically ischemic limb models. DESIGN: Twenty-seven New Zealand white rabbits were randomly assigned to three groups: (1) those in the ischemia with cuff inflation training group received right femoral artery ligation and occlusion of blood flow in the left limb by 3 mins of cuff inflation followed by 5 mins of deflation, repeated three times; (2) those in the ischemia with isometric exercise training group received right femoral artery ligation and 4 mins of isometric contraction exercise ischemic training in the left limb followed by 10 mins of rest, repeated twice; (3) those in the sole ischemia group received right femoral artery ligation and no intervention in the left limb. Five weeks later, muscle endurance, resting blood flow, and collateral angiogenesis were examined. Capillary supply, types and cross-sectional areas of muscle fibers and cellular oxidative potential were also evaluated. RESULTS: Gastronomic endurance of rabbits in the cuff inflation training group was the best among the three groups (P < 0.01). Collateral circulation (P < 0.05), distribution of type I fibers (P < 0.01), and cross-sectional area of type IIB fibers (P < 0.05) were also significantly higher in the cuff inflation training group than in the sole ischemia group. Similar differences were recorded between the isometric exercise training and sole ischemia groups. The distribution of type IIA fibers was lower (P < 0.01) in the cuff inflation training group than in the isometric exercise training group. Distribution of type IIB was found to be significantly different between these two groups (P < 0.01). CONCLUSIONS: Physiologic ischemic exercise training can promote remote angiogenesis in the pathologic ischemic skeletal muscle and thus improve performance.

The effect of high tone power therapy on gait range in patients with chronic lower limb ischaemia.

BACKGROUND: Pain-related abnormalities of the economy of walking are the most important factor adversely affecting overall physical activity of patients with chronic lower limb ischaemia. These patients are routinely managed conservatively, with the aim of improving pain-free claudication distance. The aim of this study was to examine the impact of HiToP on the functional status of the lower limbs in such patients and look for possible flow dynamics correlates in peripheral microcirculation in the lower limbs. MATERIAL AND METHODS: The study involved 68 patients aged 40-70 years, who were randomly assigned to Group A (experimental) and Group B (control). Study procedures included a treadmill test to determine the claudication distance and the measurement of blood flow in lower limb peripheral microcirculation using laser Doppler flowmetry. The intensity of lower limb pain was also determined. Patients from the experimental group were subjected to a series of HiToP sessions. The control group received mock HiToP (placebo). RESULTS: The claudication distance and maximum walking distance were significantly prolonged only in the HiToP group. With regard to microcirculation flow dynamics, only mean flow values increased substantially, but this was again only observed in the group treated with HiToP. CONCLUSIONS: HiToP makes it possible to improve lower limb function, as evidenced primarily by improved claudication distance, maximum walking distance and improved blood flow parameters in cutaneous microcirculation.

Whole-body vibration attenuates the increase in leg arterial stiffness and aortic systolic blood pressure during post-exercise muscle ischemia.

Exercise with whole-body vibration (WBV) decreases brachial-ankle pulse wave velocity (baPWV), a marker of systemic arterial stiffness. To examine the effect of WBV on arterial responses, 12 young men underwent three experimental trials: (1) no-exercise control (CON), (2) static squat with WBV, and (3) static squat without WBV (no-WBV). Bilateral baPWV and femoral-ankle PWV (faPWV), carotid-femoral PWV (cfPWV), augmentation index (AIx), first (P1) and second (P2) systolic peaks, aortic systolic blood pressure (aSBP), and heart rate (HR) were assessed at rest, during 4-min post-exercise muscle ischemia (PEMI) on the left thigh, and 4-min recovery. During PEMI, right faPWV increased (P < 0.05) after no-WBV and did not change after CON and WBV. Right baPWV, P2, and aSBP increased (P < 0.05) after both exercise trials, but the increase was lower (P < 0.05) after WBV than no-WBV. The increases in cfPWV (P < 0.05), AIx (P < 0.05), P1 (P < 0.01), and HR (P < 0.05) were similar in both trials during PEMI. During recovery, right faPWV and baPWV remained similar than rest after WBV and CON, but remained elevated (P < 0.05) after no-WBV. Aortic SBP, P1, and P2 remained elevated (P < 0.05) in both exercise trials during recovery, but the levels were lower (P < 0.05) than PEMI. Left faPWV and baPWV were reduced (P < 0.05) from rest in the three trials. CfPWV, AIx, and HR returned to resting levels in both exercises. WBV prevents the increases in faPWV and attenuates the increase in baPWV and aSBP induced by post-static squat muscle ischemia due to an attenuated P2 response.

Rehabilitative treatment in peripheral artery disease: protocol application and follow-up.

AIM: Peripheral arterial disease (PAD) is a chronic figure suitable to be treated at the II stage to prevent the extreme developments both of the critical limb ischemia and the amputation, as well. The aim of this study was to establish a rehabilitation program (pharmacological and physical) focused not only on the improvement of the flow but also on the metabolic rebalancing in the claudicant limb. METHODS: The study enrolled 222 patients, (125 non-diabetics and 97 diabetics): 54 II A and 168 II B stage; 172 patients (131 II B and 41 II A; 104 non-diabetics and 68 diabetics) were submitted to iv. L-propionil carnytine (Lpc) and physical training on treadmill or exercise bike and 50 patients to iv. therapy alone. Instrumental (Rheoscreen, Oximetry, ABI, walking distance measurement) and clinical checks (questionnaire - Appendix 1) were performed at days: T0, T45,T 90,T180, T230 and during the follow up stated at T 90,T180,T360 from T 230 (end of DH). RESULTS: A significant increasing of the walking distance has been reached in the group undergoing the rehabilitation program. Treadmill: non-diabetics +261.48% at 0% and +122.53% at slope 10% (T230) further increasing to +502.31% at 0% and +289.42% at slope 10% (T360); diabetics: + 158.49% at T0 and + 98.26% at slope 10% (T230) further increased to +287.74% at 0% and +197.39% at 10% (T360) in comparison with the group which had only iv. Lpc : non-diabetics +141.63% at 0% and +104.08% at slope 10% (T230) further increased to +202.064% at 0% and +155.10% at slope 10% (T360); diabetics: +109.124% at T0 and +100% at slop 10% (T230) further increased to +171.08% at 0% and +140% at 10% (T360) . Exercise bike: non-diabetics: +170.27% at T230 in comparison T0 increased to +305.4% at T360; diabetics: +166.66 at T230 reaching +288.88% at T 360. CONCLUSION: Our rehabilitative program gives not only good results at the end of the treatment but mainly stable, with the chance to reach further improving of both walking distance and quality of life, particularly in those patients which observe constantly the physical training.