Cardiac Rehabilitation in German Speaking Countries of Europe-Evidence-Based Guidelines from Germany, Austria and Switzerland LLKardReha-DACH-Part 2.

BACKGROUND: Scientific guidelines have been developed to update and harmonize exercise based cardiac rehabilitation (ebCR) in German speaking countries. Key recommendations for ebCR indications have recently been published in part 1 of this journal. The present part 2 updates the evidence with respect to contents and delivery of ebCR in clinical practice, focusing on exercise training (ET), psychological interventions (PI), patient education (PE). In addition, special patients' groups and new developments, such as telemedical (Tele) or home-based ebCR, are discussed as well. METHODS: Generation of evidence and search of literature have been described in part 1. RESULTS: Well documented evidence confirms the prognostic significance of ET in patients with coronary artery disease. Positive clinical effects of ET are described in patients with congestive heart failure, heart valve surgery or intervention, adults with congenital heart disease, and peripheral arterial disease. Specific recommendations for risk stratification and adequate exercise prescription for continuous-, interval-, and strength training are given in detail. PI when added to ebCR did not show significant positive effects in general. There was a positive trend towards reduction in depressive symptoms for "distress management" and "lifestyle changes". PE is able to increase patients' knowledge and motivation, as well as behavior changes, regarding physical activity, dietary habits, and smoking cessation. The evidence for distinct ebCR programs in special patients' groups is less clear. Studies on Tele-CR predominantly included low-risk patients. Hence, it is questionable, whether clinical results derived from studies in conventional ebCR may be transferred to Tele-CR. CONCLUSIONS: ET is the cornerstone of ebCR. Additional PI should be included, adjusted to the needs of the individual patient. PE is able to promote patients self-management, empowerment, and motivation. Diversity-sensitive structures should be established to interact with the needs of special patient groups and gender issues. Tele-CR should be further investigated as a valuable tool to implement ebCR more widely and effectively.

[Rehabilitation after Traumatic Fracture of Thoracic and Lumbar Spine]. / Rehabilitation nach traumatischen Frakturen der Brust- und Lendenwirbelsäule.

On the basis of the S2-k guideline "Rehabilitation after traumatic fractures of the thoracic und lumbar spine without neurologic disorder", this article gives an overview of target-oriented rehabilitation of patients with minor fractures or those with column stability and unstable spinal fractures which are stabilised by surgery. To obtain early social and job related reintegration, outpatient or inpatient rehabilitation has to start immediately after treatment in hospital. Rehabilitation must be orientated towards the biopsychosocial model of ICF and has to be adapted for the patient. The overall goal of rehabilitation is functional restoration of patient health to enable participation in society, life and job. Individual goals may change during rehabilitation, because of differential progress in therapy. Pain management must be orientated towards individual requirements and mental health has to be tested early, especially in polytrauma patients. Disorders have to be treated by psychotherapy, because psychic stress supports chronification of pain. Generally early exercise and physiotherapy are recommended in the guideline, with patient education for health-seeking behavior. Otherwise an orthesis device is not really necessary for treatment of a stable fracture. To improve the outcome of rehabilitation aftercare, treatment has to be arranged during rehabilitation, especially for employed patients.

Changes of basic bone turnover parameters in short-term and long-term patients with spinal cord injury.

The bone mineral density (BMD), the cross- links (PYD, DPD and NTx) and the bone specific alcaline phosphatase (BAP) was investigated in a cross-sectional study in 62 male patients with spinal cord injury (SCI), n = 28 short-term (0-1 year after SCI) and n = 34 long-term SCI patients (> 5 years after SCI). Knowledge about this parameters are necessary to find an adequate therapy for this special kind of osteoporosis. Immobilisation osteoporosis in SCI patients is a well-known problem that may lead to pathological fractures. Little is known regarding the extend of the osteoporosis as well as the causative factors. Measurements of the BMD in the proximal femur and the lumbar spine were performed with dual-energy-X-ray-absorptiometry (DEXA), of the osteoblast marker BAP (bone specific alkaline phosphatase) from serum and the osteoclast markers PYD (pyridinoline), DPD (desoxy-pyridinoline) and NTx (N-telopeptide of collagen type I) from urine. We found a significant decrease of BMD in the proximal femur and no relevant change in the lumbar spine compared to an age- and sex correlated control group (Z-score) in short-term and long-term SCI patients. There was a significant bone loss at the proximal femur between short and long-term SCI patients, whereas at the lumbar spine the BMD even slightly increases. Bone resorption (cross-links) was increased in both groups, though in long-term SCI patients it is significantly decreased compared to short-term SCI patients (DPD from 211.7 micro/g creatinine to 118.1 micro/g creatinine; NTx from 215.1 nmol/mmol creatinine to 83,6 nmol/mmol creatinine). The bone formation marker BAP is slightly below normal range in both groups (12.3 U/l in short-term, 9.7 U/l in long- term SCI patients). Only the proximal femur is affected by the immobilisation osteoporosis of SCI patients, therefore the BMD measurements in these patients should be performed at the lower limb. The problem of the immobilisation osteoporosis in SCI patients is the striking increase of bone resorption and the missing reaction of the bone formation.