Immunogenicity and safety of inactivated quadrivalent influenza vaccine compared with the trivalent vaccine for influenza infection: an overview of systematic reviews.

BACKGROUND: Influenza infection is a highly preventable transmissible viral disease associated with mild upper respiratory symptoms and more severe conditions such as lethal pneumonia. Studies have shown that a broader spectrum influenza vaccine could reduce influenza's burden of disease in low- and middle-income countries. A considerable number of systematic reviews reported that quadrivalent influenza vaccines are considered more effective compared to trivalent vaccines, hence, there is a need for an overview in order to synthesize the current evidence pertaining to the comparison between quadrivalent and trivalent inactivated influenza vaccines. OBJECTIVE: The aim was to summarize the evidence from systematic reviews that investigated the immunogenicity and safety of the Influenza's inactivated quadrivalent vaccine (QIV) compared to the trivalent vaccine (TIV), in the general population. METHODS: We searched articles up to December 2022 at: Web of Science, EMBASE, MEDLINE, Cochrane Library, and SCOPUS. The search strategy was conducted following the PICO model. We included systematic reviews comparing the primary outcomes of immunogenicity (seroprotection rate and seroconversion rate) and adverse events using risk ratios. The AMSTAR 2 and ROBIS were used for quality assessments, and GRADE was used for evidence certainty assessments. FINDINGS: We included five systematic reviews, totalling 47,740 participants. The Quadrivalent Inactivated Influenza Vaccine (QIV) exhibited enhanced immunogenicity in the context of B-lineage mismatch when compared to the Trivalent Inactivated Influenza Vaccine (TIV). While the safety profile of QIV was found to be comparable to that of TIV, the QIV showed a higher incidence of solicited local pain among children and adolescents, as well as an increased frequency of local adverse events within the adult population. CONCLUSION: Our findings suggest that the QIV provides a superior immunogenicity response compared to the TIV in all age groups evaluated, especially when a lineage mismatch occurred. The safety of QIV was considered similar to the TIV, with no serious or systemic solicited or unsolicited adverse events; tough pain at the injection site was greater for QIV. We recommend caution owing to the high risk of bias in the selection process and no protocol registration.

Muscle Strength Cutoff Points for Functional Independence and Wheelchair Ability in Men With Spinal Cord Injury.

OBJECTIVE: Determine trunk and shoulder muscle strength cutoff points for functional independence and wheelchair skills, and verify the predictive capacity of relative and absolute peak torque in men with spinal cord injury (SCI). DESIGN: Cross-sectional study. SETTING: Rehabilitation hospital setting. PARTICIPANTS: Men (N=54) with SCI were recruited and stratified into high and low paraplegia groups. INTERVENTIONS: All participants performed maximum strength tests for shoulder abduction or adduction (isokinetic) and trunk flexion or extension (isometric) to determine relative and absolute peak torque cutoff points for the Spinal Cord Independence Measure version III (SCIM-III) and Adapted Manual Wheelchair Circuit (AMWC). MAIN OUTCOME MEASURES: The primary outcome measures were SCIM-III, AMWC-Brazil test, and strength variables (peak torques). Demographic characteristics obtained from participants' electronic medical records were the secondary outcomes used as predictor variables of functional independence. RESULTS: The best predictive model for SCIM-III (R=0.78, P≤.05) used the sum of trunk flexion and extension relative peak torque values to determine the cutoff points (1.42 N·m/kg for a score of 70). Relative shoulder abduction peak torque was used in the predictive models for AMWC outcomes: performance score (R=0.77, P≤.05, cutoff points of 0.97 N·m/kg for 300.0m) and 3-minute overground wheeling (R=0.72, P≤.05, cutoff points of 0.96 N·m/kg for 18.5s). CONCLUSIONS: Relative peak torque showed better predictive capacity compared to absolute peak torque. Cutoff points were established for relative muscle strength and could help health professionals set appropriate goals for individuals with SCI to achieve high functional independence and wheelchair ability.

Are Body Composition, Strength, and Functional Independence Similarities Between Spinal Cord Injury Classifications? A Discriminant Analysis.

CONTEXT: There seems to be no consensus on which aspects better distinguish the different levels of spinal cord injury regarding body composition, strength, and functional independence. OBJECTIVE: The study aimed to determine which variables better differentiate tetraplegia (TP) from paraplegia and high paraplegia (HP) from low paraplegia (LP). DESIGN: Cross-sectional study. SETTING: Rehabilitation hospital network. PATIENTS: Forty-five men with spinal cord injury, n = 15 for each level (TP, HP, and LP) causing complete motor impairment (American Spinal Injury Association Impairment Scale: A or B) were enrolled in the study. MAIN OUTCOME MEASURES: The 1-maximum repetition test, functional independence measure, spinal cord independence measure, and body composition (skinfold sum, body fat percentage, and body mass index) were assessed. Discriminant analysis was carried out using the Wilks lambda method to identify which strength and functional variables can significantly discriminate subjects for injury classification (TP, HP, and LP). RESULTS: The discriminant variable for TP versus HP was body mass index and for TP versus LP was 1-maximum repetition (P ≤ .05). There were no variables that discriminated HP versus LP. CONCLUSIONS: The discriminant variables for TP versus HP and TP versus LP were body mass index and 1-maximum repetition, respectively. The results showed that HP and LP are similar for strength and functional variables.

Differences of Relative and Absolute Strength of Individuals With Spinal Cord Injury From Able-Bodied Subjects: A Discriminant Analysis.

CONTEXT: Strength training is one of the most common interventions employed to increase functional independence during rehabilitation of individuals with spinal cord injury (SCI). However, in the literature, different results have been reported in terms of strength modifications after a SCI compared with a control group (CG). OBJECTIVE: This study aimed to verify whether discriminant analysis using relative and absolute strength is able to discriminate individuals with different levels of SCI from a CG and to compare strength values of men with different levels of SCI with a CG. DESIGN: Cross-sectional study. SETTING: Rehabilitation hospital setting. PARTICIPANTS: A total of 36 individuals with SCI stratified in tetraplegia (TP; C6-C8), high paraplegia (HP; T1-T6), and low paraplegia (LP; T7-L2), and 12 matched control subjects were enrolled in the study. MAIN OUTCOME MEASURES: The subjects performed a maximum strength test of elbow extension/flexion and also shoulder abduction/adduction and flexion/extension in an isokinetic dynamometer. Discriminant analysis was carried out to identify which strength variables would be able to discriminate the TP, HP, or LP groups from the CG. A 1-way analysis of variance was performed to compare peak torque and agonist/antagonist ratio means. RESULTS: Shoulder adduction, followed by elbow extension peak torque, was the best variable for discriminating the TP group from the CG (function coefficients: -0.056 and 0.051, respectively, Wilks Λ = 0.41, P ≤ .05). There were no significant differences between the HP group, LP group, and CG. CONCLUSIONS: The strength similarity of the paraplegic groups and the CG should not be extrapolated for activities of daily living or sports. The TP group demonstrated lower peak torque for all movements than the CG.

Musculoskeletal discomfort, work ability and fatigue in nursing professionals working in a hospital environment. / Desconforto musculoesquelético, capacidade de trabalho e fadiga em profissionais da enfermagem que atuam em ambiente hospitalar.

OBJECTIVE: To evaluate the musculoskeletal discomfort, work ability and residual fatigue in nursing professionals working in the hospital setting. METHOD: Cross-sectional study with professionals from a medium-sized public hospital. The Nordic symptom questionnaire, the work ability index, and the need for recovery scale (fatigue) were used. Data were analyzed descriptively and inferential tests were applied in order to verify the association of fatigue and work ability, and compare the fatigue among sectors analyzed. RESULTS: Participation of 110 professionals in the study. A total of 86.24% of workers reported musculoskeletal discomfort, with a higher prevalence in the cervical, thoracic and lumbar spine. Approximately 43% of professionals presented residual fatigue. There was a significant association between fatigue and reduction of work ability (p<0.003), as well as association between younger age and greater fatigue (p<0.03). CONCLUSION: Results demonstrated a high prevalence of musculoskeletal discomfort in the previous year and a considerable number of professionals with residual fatigue. There was a substantial portion of workers with moderate work ability and requiring attention in the medium term.

Kinematic gait analysis using inertial sensors with subjects after stroke in two different arteries.

[Purpose] The aim of the present study was described the kinematic characteristics of gait in stroke patients with two different arteries involved. [Subjects and Methods] Two patients who had suffered a basilar (A) or middle (B) cerebral artery ischemic stroke were compared with a control (C). Seventeen inertial sensors were used with acquisition rate of 120 Hz. The participants walked 3 times on a 10 meter walkway. From the raw data, the three gait cycles from the middle of each trial were chosen and analyzed. [Results] During the stance phase, patients A and B had a lower hip angle at initial contact and maximum flexion angle during load response than the control. Patient A and the control subject had similar knee angle values at initial contact, and patient B presented a flexed position in the initial phase of the gait cycle. The maximum flexion angles during loading response were also higher for patient B. The sagittal plane excursion for the ankle joint was lower for patient B in comparison with the other subjects. [Conclusion] Differences during walking between patients who had stroke in different arteries may be related to an alternative compensatory strategy. Patient A and the control subject had similar gait cycle curves at all joints, while patient B showed a rigid synergic pattern.

Economic burden of depression in Brazil: a cost-of-illness study based on productivity losses and healthcare costs between 2010 to 2018.

BACKGROUND: Depression is disabling disorder and cause functional impairments, and high costs for the health and social security system. OBJECTIVE: The direct and indirect costs of depression from the societal perspective were estimated for the period 2010 to 2018. METHODS: This cost-of-illness study in adults is based on prevalence, with a top-down approach, from the societal perspective. Direct (hospital and outpatient) and indirect (absenteeism) costs were included. Data were extracted from the Hospital and Outpatient Information Systems and the National Social Security Institute. RESULTS: The cost of depression was Int$ 2,288,511,607.39 in the analyzed period, with an average annual cost of Int$ 254,279,067.49. From 2014 to 2018, had a sharp and persistent decrease in the cost of depression (-44.24%), mainly in indirect costs (-55.83%). In the period investigated, indirect costs represented 74.85% of the total cost. Over time, outpatient surpassed hospital cost. In 2017 and 2018, outpatient costs represented 43.22% and 39.57% of total costs. In all the years and cost components analyzed, women predominated. CONCLUSIONS: Depression is a disease with a high economic burden for the healthcare system. Investments are still needed, such as higher coverage of services, multidisciplinary teams, and training of health professionals for psychosocial care.

Direct healthcare cost of hospital admissions for chronic non-communicable diseases sensitive to primary care in the elderly. / Custo direto de internações hospitalares por doenças crônicas não transmissíveis sensíveis à atenção primária em idosos.

Aging has imposed changes in the epidemiological profile and an increase in the prevalence of chronic non-communicable diseases (CNCDs). The aim was to estimate the direct cost related to hospital admissions of elderly people affected by CNCDs (hypertension, heart failure and diabetes mellitus) sensitive to primary care, in a medium-sized hospital, in the period 2015-2019. Secondly, we investigated whether clinical and demographic factors explain the costs and length of stay. The medical records of 165 elderly people were analyzed. We found a predominance of women with a mean age of 76.9 years. The most frequent cause of hospitalization was heart failure (62%), and the average length of stay was 9.5 days, and 16% of hospitalizations corresponded to rehospitalizations. Of these, 81% were caused by complications from the previous hospitalization. The estimated total cost was R$ 3 million. Male patients had a longer hospital stay compared to female patients. Hypertension and the total number of procedures were significant predictors of cost and length of stay. We found that in 5 years, the costs of hospital admissions for conditions sensitive to primary care in the elderly are considerable, indicating the relevance of investments in primary care.

O envelhecimento tem imposto mudanças epidemiológicas e aumento na prevalência de doenças crônicas não-transmissíveis (DCNT). O objetivo foi estimar o custo direto relacionado às internações hospitalares de idosos acometidos por DCNT (hipertensão arterial, insuficiência cardíaca e diabetes mellitus) sensíveis à atenção primária, em hospital de médio porte, no período de 2015-2019. Secundariamente, investigamos se fatores clínicos e demográficos explicam o custo e tempo de permanência. Foram analisados prontuários de 165 idosos. Verificamos predominância de mulheres com média de idade de 76,9 anos. A causa de internação mais frequente foi insuficiência cardíaca (62%) e o tempo médio de permanência foi de 9,5 dias, e 16% das internações corresponderam a idosos reinternados. Dessas, 81% foram causadas por complicações da internação anterior. O custo total estimado foi de R$ 3 milhões. Pacientes do sexo masculino ficaram mais tempo internados, comparado ao sexo feminino. Hipertensão e o total de exames realizados foram preditores significantes do custo e tempo de permanência. Verificamos que em 5 anos, os custos com internações hospitalares por condições sensíveis à atenção primária em idosos são consideráveis, indicando a relevância de investimentos na atenção primária.

The care pathway of individuals with spinal disorders in a Health Care Network in the Federal District, Brazil: a retrospective study.

BACKGROUND: Understanding the care pathway is essential to identify how to effectively treat spinal disorders. However, there is no specific data on the pathway of these individuals in the Health Care Networks (HCN) in Brazil. OBJECTIVE: To investigate the pathway of individuals with non-specific spinal disorders (NSD) in the HCN in the Federal District, Brazil, and verify the interventions adopted, and to test whether sociodemographic and clinical variables predict the number of imaging tests, prescribed medication, and the first HCN access. METHODS: Retrospective study that analysed electronic records of 327 individuals with NSD between 2012 and 2018. Generalized linear models estimated the association between sociodemographic and clinical data and number of drugs prescribed and imaging tests requested. Multinomial logistic regression estimated the association between clinical and demographic variables and setting of first access. RESULTS: The median age was 57 years, and 75.5% were women. Emergency Department (ED) was the most accessed setting (43.7%), and back pain was the most prevalent condition (84.5%). Most individuals underwent imaging tests (60%) and drug prescriptions (86%). Physical exercises were prescribed to 13%, and 55% were referred to physical therapy. Women were more likely to first access the ED. CONCLUSION: The ED was the most used setting by people with NSD. Few participants received exercise prescriptions and half were referred to physical therapists. Individuals who used outpatient clinics and primary care received less drug prescriptions, and women were more likely to first access the ED. Increasing age was associated with greater chance of first accessing Outpatient Clinics.

Characterization of the procedures and professional practices of primary care physiotherapists in Brazil.

BACKGROUND: Physiotherapy interventions are well known and established in secondary and tertiary care. However, within the Brazilian primary health care (PHC), the role of physiotherapists is still under development, and there is a lack of representative data showing how and what is being implemented by these professionals. OBJECTIVE: The aim was to characterize the professional practices of physiotherapists working at PHC in Brazil. METHODS: This is an exploratory study that adopted a descriptive analysis based on the records of physiotherapists, considering assistance and sociodemographic aspects, in the period from 2016 to 2017. The following variables were extracted: region, federative unit and municipality, age group and sex of the attended user, condition/problem, procedure and place of attendance. RESULTS: A total of 318,780 procedures were recorded, concentrated in the South and southeast regions, with a predominance of clinical-assistance procedures and a higher frequency of attendance in Basic Health Units. Among the assisted users, the female gender prevailed in the age group of 20 to 59 years. Low back pain was the most frequently treated condition. CONCLUSION: The professional practices of physiotherapists working at PHC in Brazil were characterized by healthcare, clinical-assistance, preventive and health promotion activities, with emphasis on clinical-assistance practices focused on musculoskeletal conditions, especially low back pain.

Direct costs of prematurity and factors associated with birth and maternal conditions.

OBJECTIVE: To estimate the direct costs due to hospital care for extremely, moderate, and late preterm newborns, from the perspective of a public hospital in 2018. The second objective was to investigate whether factors associated with birth and maternal conditions explain the costs and length of hospital stay. METHODS: This is a cost-of-illness study, with data extracted from hospital admission authorization forms and medical records of a large public hospital in the Federal District, Brazil. The association of characteristics of preterm newborns and mothers with costs was estimated by linear regression with gamma distribution. In the analysis, the calculation of the parameters of the estimates (B), with a confidence interval of 95% (95%CI), was adopted. The uncertainty parameters were estimated by the 95% confidence interval and standard error using the Bootstrapping method, with 1,000 samples. Deterministic sensitivity analysis was performed, considering lower and upper limits of 95%CI in the variation of each cost component. RESULTS: A total of 147 preterm newborns were included. We verified an average cost of BRL 1,120 for late preterm infants, BRL 6,688 for moderate preterm infants, and BRL 17,395 for extremely preterm infants. We also observed that factors associated with the cost were gestational age (B = -123.00; 95%CI: -241.60 to -4.50); hospitalization in neonatal ICU (B = 6,932.70; 95%CI: 5,309.40-8,556.00), and number of prenatal consultations (B = -227.70; 95%CI: -403.30 to -52.00). CONCLUSIONS: We found a considerable direct cost resulting from the care of preterm newborns. Extreme prematurity showed a cost 15.5 times higher than late prematurity. We also verified that a greater number of prenatal consultations and gestational age were associated with a reduction in the costs of prematurity.

Muscle strength in Brazilian firefighters with non-specific chronic low back pain: A cross-sectional study.

BACKGROUND: Imbalance between flexor and extensor muscles of the trunk could negatively influence spinal stability. OBJECTIVES: Investigate the strength balance between flexor and extensor muscles of the trunk in military firefighters with non-specific chronic low back pain (NSCLBP). METHODS: One hundred and two male firefighters were assessed in an isokinetic dynamometer at 120°/s and 60°/s to investigate the balance ratio between flexor and extensor (F/E) muscles. RESULTS: An F/E ratio of 0.72 (SD: 0.22; 95% CI: 0.67-0.76; SEM: 0.02) was observed at 60°/s and 0.94 (SD: 0.41; 95% CI: 0.85-1.03; SEM: 0.04) at 120°/s. The mean peak torque of the extensor muscles was 343.1 N.m/Kg (SD: 94.87; 95% CI: 322.8-363.5; SEM: 10.23) at 60°/s and 270.5 N.m/Kg (SD: 113; 95% CI 246.3-294.8; SEM: 12.18) at 120°/s. The mean peak torque of the flexor muscles was 232.4 N.m/Kg (SD: 53.86; 95% CI 220.8-243.9; SEM: 5.81) at 60°/s and 223.8 N.m/Kg (SD: 66.34; 95% CI 209.6-238.1; SEM: 7.15) at 120°/s. All torques generated by the extensor muscles were higher than the flexor muscles (p < 0.05). CONCLUSIONS: Firefighters with NSCLBP presented a normal F/E balance ratio and higher strength of extensor muscles of the trunk.

Accuracy and cut-off points of different models of knee extension strength analysis to identify walking performance in individuals with chronic stroke.

BACKGROUND: Adequate muscle strength is essential for walking performance in individuals with stroke. OBJECTIVE: To investigate the accuracy of different forms of muscle knee extension strength analysis to identify high or low walking performance in individuals with chronic stroke. METHODS: Twenty-eight participants with a chronic stroke for more than six months participated. Independence for walking was judged by measurement of walking performance assessed for comfortable walking speed (CWS), maximum walking speed (MWS), and the Six Minute Walk Test (6MWT). Peak knee extension torque of the paretic side, non-paretic side, sum of the sides (SS), and difference in the sides (DS) was assessed during concentric movements using an isokinetic dynamometer. RESULTS: The equation with greatest predictive capacity for CWS and MWS included the DS as the main predictor (R2 of 0.65 and 0.71, respectively, p < 0.05). The variable with the greatest predictive capacity for 6MWT was time since injury (R2 of 0.68, p < 0.05). The highest percentile for CWS in the receiver operating characteristic curve of DS was 25 Nm/kg (cut-off: -12.75 for CWS of 0.498 m/s). The 75th percentile of the 6MWT (324.3 m) was used as the cut-off for the SS (2.1 Nm/kg). The area under the curve for CWS was 0.76 (p < 0.05) on the DS and 0.75 (p < 0.05) for 6MWT on the SS. CONCLUSION: The models of muscle knee extension strength analysis using the SS and DS presented moderate accuracy to identify walking performance in individuals with chronic stroke.

Acute effects of different rest intervals between agonist-antagonist paired-sets in the neuromuscular system performance of young adults.

INTRODUCTION: The agonist-antagonist paired-sets (APS) is a resistance training that involves alternating between exercises for agonist/antagonist muscles of a joint, with little or no rest between then. There is evidence that APS is more strenuous than traditional methods, but evidence on the optimal RI between agonist-antagonist actions is unknown. OBJECTIVE: The aim of this study was to compare different rest intervals between agonist-antagonist actions during APS in young adults. METHOD: Fifty healthy men (mean age 23.2 ± 2.8 years; 1.76 ± 0.1m height, 78.03 ± 8.1 kg) were included and performed three different agonist-antagonist paired-sets protocols separated by 72h, consisting of 4 sets of 10 repetitions. The protocols differed in terms of the rest interval between the knee flexion and extension movements: 0s (no rest); 60s and 120s. The rest intervals between exercise sets were standardized at 60s. Total work, peak torque, neuromuscular efficiency, surface EMG amplitude (sEMG, root mean square) and fatigue index obtained by processing of sEMG signal, were compared between rest intervals and exercise sets within each protocol. RESULTS: There were no significant differences between rest intervals for total work, peak torque and neuromuscular efficiency (P > 0.05), but significant differences were found for sEMG and fatigue (P < 0.01), in which the protocol with 60s interval resulted in greater fatigue. CONCLUSION: We showed that peak torque, total work and neuromuscular efficiency were not different between RI. The 60s RI showed a lower sEMG and a greater muscle fatigue. Although there were no significant differences, the NME was higher in the 60s interval.

The addition of three new items in the Adapted Manual Wheelchair Circuit improves the discrimination between different levels of spinal cord injury.

Purpose: To determine whether the inclusion of three additional items improved the discriminative capacity of the Adapted Manual Wheelchair Circuit (AMWC). Design: Cross-sectional study. Methods: A total of 126 men (median age 28.9 years [percentiles 25 and 75: 23.7; 38.5 years]) with spinal cord injury were consecutively enrolled and divided into three subgroups: high paraplegia (HP), medium paraplegia (MP), and low paraplegia (LP). The participants performed the AMWC with three additional items. Ability score and total time of AMWC (AMWCAS and AMWCTT) and AMWC plus the three additional items (AMWC+3AS and AMWC+3TT), 3 min of overground wheeling test and performance score were evaluated. Results: AMWC was not able to discriminate HP from MP and LP (Wilks' lambda = 0.93; P= 0.07). In contrast, AMWC+3 was able to discriminate between the three subgroups (Wilks' lambda = 0.86; P≤ 0.05). AMWC+3AS presented a better sensitivity compared to AMWCAS (lower success rate for all subgroups, 38.5% vs. 82.1% for HP; 49.0% vs. 75.5% for MP; 78.9% vs. 94.7% for LP). The LP group presented a significant higher AMWC+3AS compared to MP and HP (17.0 vs. 16.5 and 16.5, respectively, P≤ 0.05). AMWC+3TT was significantly lower in LP compared to MP and HP (139.85 s vs. 242.52 s and 326.21 s, respectively, P≤ 0.05). Conclusion: The AMWC+3 outcomes were able to discriminate between HP, MP, and LP subgroups, and the addition of the three items enhanced the sensitivity of the wheelchair circuit. The performance of LP was more evident with significant differences compared to HP and MP for all AMWC+3 outcomes.

Does prolonged walking cause greater muscle fatigability in individuals with incomplete spinal cord injury compared with matched-controls?

BACKGROUND: Individuals with incomplete spinal cord injury (iSCI) might show muscle fatigability during walking, primarily over long distances. The cause can be related to the motor impairment and walking compensations identified in this population. However, evidence on the occurrence of muscle fatigability after prolonged walking in individuals with iSCI is conflicting. RESEARCH QUESTION: Does prolonged walking cause higher muscle fatigability in individuals with iSCI compared with matched-controls? METHODS: We adopted a repeated measures design, in which maximal voluntary isometric contractions were performed before and after a walking test to induce the fatigability, in 24 individuals with iSCI and 24 matched-controls. Body weight-normalized peak torque (PT/BW), rate of force development (RFD), root mean square (RMS) and neuromuscular efficiency were used to assess the muscle fatigability. A mixed model ANOVA (2 × 2) was used for between-group and within-group comparisons. The significance was set in 5%. RESULTS: Individuals with iSCI showed a greater decline in the PT/BW and RMS after the walking test. However, the RFD presented a greater decrease in the control group. SIGNIFICANCE: Our results showed that prolonged walking caused higher muscle fatigability in individuals with iSCI compared to healthy individuals. Therefore, muscle fatigability should be considered during the rehabilitation planning and in activities of daily living of individuals with iSCI. Moreover, the identification of muscle fatigability in individuals with iSCI might be useful to prevent high levels of physical exertion and, possibly, the risk of fall.

Low back pain should be considered a health and research priority in Brazil: Lost productivity and healthcare costs between 2012 to 2016.

BACKGROUND: Low Back Pain (LBP) is associated with an increase in disability-adjusted life years, and increased risk of disability retirement and greater absenteeism in Brazil. Hence, evidence on healthcare and lost productivity costs due to LBP is of utmost importance to inform decision-makers. METHODS: Cost-of-illness study with top-down approach, and societal perspective. We extracted data from National databases, considering the period 2012-2016. Outpatient expenses included clinical, surgical, diagnosis, orthosis/prosthetics, and complementary actions. Inpatient care expenses included hospital and professional services, intensive care unit, and companion stay. For productivity losses, duration of work absence and associated information (work-related and non-work-related; value of the sickness absence benefit; age; gender; and economic activity) were analyzed. Lost productivity costs were calculated multiplying the absence from work (days) by the daily-benefit. RESULTS: The societal costs amounted to US$ 2.2 billion, and productivity losses represented 79% of the costs. Total healthcare expenses were estimated to US$ 460 million. We found more than 880,000 diagnostic images. Individuals with LBP were in total 59 million days absent from work between 2012-2016. The mean lost days absent from work per person, for each year investigated was, respectively, 88; 84; 83; 87; and 100. Men were more days absent from work than women. In addition, rural workers presented greater absence from work compared to other professional activities. CONCLUSION: Healthcare expenses and lost productivity costs due to LBP were substantial, hence, there is a need for improvement of health services and policies to deal with this increasing burden of illness. We found an extensive use of diagnostic imaging, which is rather discouraged by clinical guidelines. We assume that men were experiencing high levels of back pain disability compared with women, as they presented greater absenteeism and higher lost productivity costs.

Effectiveness of spinal manipulation and myofascial release compared with spinal manipulation alone on health-related outcomes in individuals with non-specific low back pain: randomized controlled trial.

OBJECTIVE: To investigate the effectiveness of spinal manipulation combined with myofascial release compared with spinal manipulation alone, in individuals with chronic non-specific low back pain (CNLBP). DESIGN: Randomized controlled trial with three months follow-up. SETTING: Rehabilitation clinic. PARTICIPANTS: Seventy-two individuals (between 18 and 50 years of age; CNLBP ≥12 consecutive weeks) were enrolled and randomly allocated to one of two groups: (1) Spinal manipulation and myofascial release - SMMRG; n=36) or (2) Spinal manipulation alone (SMG; n=36). INTERVENTIONS: Combined spinal manipulation (characterized by high velocity/low amplitude thrusts) of the sacroiliac and lumbar spine and myofascial release of lumbar and sacroiliac muscles vs manipulation of the sacroiliac and lumbar spine alone, twice a week, for three weeks. MAIN OUTCOME MEASURES: Assessments were performed at baseline, three weeks post intervention and three months follow-up. Primary outcomes were pain intensity and disability. Secondary outcomes were quality of life, pressure pain-threshold and dynamic balance. RESULTS: No significant differences were found between SMMRG vs SMG in pain intensity and disability post intervention and at follow-up. We found an overall significant difference between-groups for CNLBP disability (SMG-SMMRG: mean difference of 5.0; 95% confidence interval of difference 9.9; -0.1), though this effect was not clinically important and was not sustained at follow-up. CONCLUSIONS: We demonstrated that spinal manipulation combined with myofascial release was not more effective compared to spinal manipulation alone for patients with CNLBP. CLINICAL TRIAL REGISTRATION NUMBER: NCT03113292.

The Torque Referenced to a Perceived Exertion Level Is Affected by the Type of Movement in Men With Spinal Cord Injury.

OBJECTIVES: To compare a standardized submaximal intensity (based on the rate of perceived exertion [RPE]) with the percentage of the average and peak torque during a familiarization session in individuals with different spinal cord injury (SCI) levels in gravity-resisted and gravity-assisted movements. METHODS: This was a cross-sectional study at a rehabilitation hospital. Thirty-six individuals stratified in tetraplegia (TP), high paraplegia (HP), and low paraplegia (LP) groups and 12 matched control participants (CG) were enrolled in the study. Participants performed a maximum strength test using isokinetic dynamometry. The familiarization consisted of 10 submaximal repetitions with a level 2 (i.e., 20% of the maximum score) in the Resistance Exercise Scale (OMNI-RES). Fisher's exact test compared the percentages of the average torque (%ATFam) and peak torque (%PTFam) of the familiarization (based on the peak torque during the maximum strength tests) to the %ATFam and %PTFam attained with 20% of RPE. The coefficient of variation (CV) was calculated to assess the torque dispersion during each familiarization set. RESULTS: The %ATFam was lower for gravity-assisted compared to gravity-resisted movements for HP, LP, and CG (p ≤ .05). The CV was significantly lower in gravity-resisted movements during familiarization for TP, LP, and CG. CONCLUSION: Different RPE levels should be adopted for gravity-resisted or gravity-assisted upper limb exercises to maintain the same relative intensity during a familiarization session.

Direct healthcare costs of spinal disorders in Brazil.

OBJECTIVES: To estimate the direct healthcare costs of spinal disorders in Brazil over 2016. METHODS: This is a prevalence-based cost-of-illness study with a top-down approach from the perspective of the public healthcare system. All international Classification of Diseases codes related to spinal disorders were included. The following costs were obtained: (1) hospitalization; medical professional service costs; intensive care unit costs; companion daily stay; (2) outpatient (services/procedures). Data were analyzed descriptively and costs presented in US$. RESULTS: The healthcare system spent US$ 71.4 million, and inpatient care represented 58%. The number of inpatient days was 250,426, and there were 36,654 hospital admissions (dorsalgia and disk disorders representing 70% of the costs). More than 114,000 magnetic resonance scans and 107,000 computerized tomography scans were adopted. Men had more inpatient days (138,215) than women (112,211). Overall, the inpatient/outpatient cost ratio was twice as high for men. CONCLUSIONS: We demonstrated that the direct costs of spinal disorders in Brazil in 2016 were considerable. We also found a substantial amount of financial resources spent on diagnostic imaging. This is relevant as the routine use of diagnostic imaging for back pain is discouraged in international guidelines.