Importancia de la investigación sobre políticas y sistemas de salud para el fortalecimiento de la rehabilitación en los sistemas sanitarios. Un llamado a la acción para acelerar el progreso / Importance of health policy and systems research for strengthening rehabilitation in health systems. A call to action to accelerate progress.

Durante las últimas décadas, el campo de la rehabilitación ha experimentado un desarrollo, crecimiento y aceptación sustanciales. La rehabilitación es un conjunto de intervenciones que aborda el impacto de una afección médica en la vida cotidiana de una persona de tal manera que optimiza su funcionamiento y reduce su experiencia de discapacidad. Del mismo modo, la rehabilitación amplía el enfoque de la salud más allá de la atención preventiva y curativa para garantizar que las personas con un problema de salud puedan continuar siendo lo más independientes posible y participando en la educación, el trabajo y los roles significativos de la vida1. Recientemente se ha publicado una definición de rehabilitación para fines investigativos2. La investigación científica y clínica ha generado un cúmulo de conocimientos que respaldan firmemente el uso de muchas intervenciones de rehabilitación con resultados positivos en diversas poblaciones y problemas de salud.

Over the past few decades, the field of rehabilitation has experienced substantial development, growth and acceptance. Rehabilitation is a set of interventions that addresses the impact of a medical condition on a person's daily life in a way that optimizes their functioning and reduces their experience of disability. Similarly, rehabilitation broadens the focus of healthcare beyond preventive and curative care to ensure that people with a health condition can continue to be as independent as possible and participate in education, work and meaningful life roles1. A definition of rehabilitation has recently been published for research purposes2. Scientific and clinical research has generated a body of knowledge that strongly supports the use of many rehabilitation interventions with positive outcomes in a variety of populations and health problems. scientific and clinical research has generated a body of knowledge that strongly supports the use of many rehabilitation interventions with positive outcomes in a variety of populations and health problems.

Evidence for isokinetic and functional testing in return to sport decisions following ACL surgery.

The rupture and reconstruction of the anterior cruciate ligament (ACL) of the knee are associated with an increased risk of functional instability, a reduction in sports performance, and a higher risk of future additional injuries. Competitive athletes who participate in sports that require pivoting, cutting, and jumping are at particularly high risk for ACL rupture. The return to sport progression continuum after surgery includes sports-specific rehabilitation, evaluation of strength and function, gradual participation in exercise training with progressively challenging activities in the field of play, participation in sports at a lower level, and finally a return to preinjury-level sports competition. This narrative review evaluates the evidence that supports the use of quadriceps and hamstrings isokinetic strength testing and sports-specific functional skills assessments to evaluate progress with rehabilitation after ACL surgery. Strength evaluations, hop tests, agility tests, and the limb symmetry index are described, as well as the associations of quadriceps and hamstrings muscle strength and functional test results with successful return to sports and the risk of ACL graft rupture and contralateral knee injuries. Suggestions for future research directions are presented including the importance of presurgery testing, standardization of test batteries, and comparison of test results with normative data.

Medicina física y rehabilitación durante y después de la pandemia: una breve reflexión / Physical medicine and rehabilitation during and after the pandemic: a brief reflection

La pandemia declarada por la Organización Mundial de la Salud debido ala enfermedad de lCovid-19 ha tenido un impacto considerable en todas las actividades humanas, incluyendo los sistemas de salud y todo lo relacionado con la prestación de los servicios médicos que necesita la población. Las instituciones que brindan servicios de Medicina Física y Rehabilitación (MF y R) no son la excepción y las acciones necesarias tomadas por los gobiernos han tenido una incidencia, en algunos casos ,severa en los servicios hospitalizados de rehabilitación, las clínicas ambulatorias ,los servicios de rehabilitación a nivel de la comunidad, los programas de educación médica graduada o residencia, y los esfuerzos de investigación en especial aquellos de naturaleza clínica.

The pandemic declared by the World Health Organization due to Covid-19 disease has had a considerable impact on all human activities, including health systems and everything related to the provision of medical services needed by the population. Institutions providing Physical Medicine and Rehabilitation (PM&R) services are no exception and the necessary actions taken by governments have had an impact, in some cases severe, on inpatient rehabilitation services, outpatient clinics, community-based rehabilitation services, graduate medical education or residency programs, and research efforts, especially those of a clinical nature.

Passive force and viscoelastic properties of single fibers in human aging muscles.

PURPOSE: Changes in stiffness or extensibility of the muscle or muscle-tendon unit with aging could lead to impaired function and an increased vulnerability to injury. We aimed to investigate the passive force and viscoelastic properties of single muscle fibers in older adults. METHODS: Seven older adults (mean age 79.0 ± 3.8 years) and 10 young control (mean age 25.6 ± 4.5 years) were recruited. Biopsy specimens were obtained percutaneously from m. vastus lateralis and skinned single fibers were used for the experiments. Slack tests were performed to determine maximal force and maximal unloaded shortening velocity. Passive force was measured in pCa 9.0 solution using a stepwise stretch technique with increment of sarcomere length from 2.4 to 4.2 µm. Myosin heavy chain (MHC) isoform was determined by sodium dodecyl sulfate-polyacrylamide gel electrophoresis. Specific force was calculated as maximal force divided by cross-sectional area. Passive force, peak passive force, time to half stress relaxation (T1/2) and force decay index (a force time integral under a stress relaxation curve) were measured. RESULTS: No difference between the groups were found in specific force and shortening velocity. Passive force and peak passive force were greater in both MHC I and IIa fibers of older adults (p < 0.001, p = 0.012, respectively, at 4.2 mm SL). Force decay index was higher in older adults. (p = 0.001 at 4.2 µm SL). There were no significant differences in passive force and viscoelastic properties between fiber types. CONCLUSION: We demonstrated greater passive force and viscoelastic properties at the level of single fibers in older adults.

Apoptosis in young and old denervated rat skeletal muscle.

INTRODUCTION: We investigated the apoptotic response to different degrees of denervation in young and older rats randomized into control (C), partial (PD), and complete denervation (CD) of muscles innervated by the sciatic nerve. METHODS: Muscle wet weight to body weight (MWW/BW), myosin heavy chain (MHC) isoforms, and fiber cross-sectional area were determined in gastrocnemius and soleus muscles. Apoptotic responses were determined by changes in myonuclei and expression of Bcl-2 and BAX. RESULTS: PD and CD resulted in significant reductions in MWW/BW and FCSA in both young and older rats. Older controls had greater apoptotic responses than young controls. Apoptotic responses were greater in PD and CD than in C in both age groups. No statistical interaction between denervation and age group was seen. CONCLUSIONS: Older age was associated with increased level of apoptosis, but older muscle was not more vulnerable to the effect of denervation. Muscle Nerve 55: 262-269, 2017.

Single muscle fiber contractile properties in diabetic RAT muscle.

INTRODUCTION: Diabetes is associated with accelerated loss of muscle mass and function. We compared the contractile properties of single muscle fibers in young rat soleus muscle of uncontrolled streptozotocin-induced diabetic animals (n = 10) and nondiabetic controls (n = 10). METHODS: Single fiber maximal force, shortening velocity, and power were assessed during maximal activation with calcium using the slack test 4 weeks after induction. Myosin heavy chain expression was determined using sodium dodecyl sulfate polyacrylamide gel electrophoresis. Oxidized myosin levels were detected by analyzing protein carbonyls in muscle homogenates. All fibers expressed the type I myosin heavy chain isoform. RESULTS: Diabetic rats had higher blood glucose (537 vs. 175 mg/dl; P < 0.001) and lower body weight (171 vs. 356 g; P < 0.001) than controls. Muscle fibers from diabetic rats showed smaller cross-sectional area (1128 vs. 1812 µm(2) ), lower maximal force (258 vs. 492 µN), and reduced absolute power (182 vs. 388 µN FL/s) (all P < 0.0001). No differences were seen in shortening velocity, specific force or specific power. Myosin carbonylation was higher (P < 0.01) in diabetic rats. CONCLUSIONS: After 4 weeks of untreated diabetes, there are significant alterations in muscle at the level of isolated single fibers and myosin protein, although some contractile properties seem to be protected. Muscle Nerve, 2015 Muscle Nerve 53: 958-964, 2016.

Principles of exercise physiology: responses to acute exercise and long-term adaptations to training.

Physical activity and fitness are associated with a lower prevalence of chronic diseases, such as heart disease, cancer, high blood pressure, and diabetes. This review discusses the body's response to an acute bout of exercise and long-term physiological adaptations to exercise training with an emphasis on endurance exercise. An overview is provided of skeletal muscle actions, muscle fiber types, and the major metabolic pathways involved in energy production. The importance of adequate fluid intake during exercise sessions to prevent impairments induced by dehydration on endurance exercise, muscular power, and strength is discussed. Physiological adaptations that result from regular exercise training such as increases in cardiorespiratory capacity and strength are mentioned. The review emphasizes the cardiovascular and metabolic adaptations that lead to improvements in maximal oxygen capacity.

Sex differences in single muscle fiber power in older adults.

PURPOSE: This study was conducted to determine whether differences in power at the single muscle fiber level contribute to sex differences in whole muscle power production in the elderly. METHODS: A total of 16 sedentary older persons (10 women, 6 men), mean age 72 yr, had percutaneous needle biopsy of musculus vastus lateralis. Chemically skinned single muscle fibers were activated with Ca for maximal isometric force measurement (Po). The slack test was performed to determine maximal unloaded shortening velocity (Vo). Force-velocity and power curves were generated via a series of isotonic contractions, allowing measurement of peak power and specific power. Sodium dodecyl sulfate-polyacrylamide gel electrophoresis (SDS-PAGE) was used to determine myosin heavy chain composition of single muscle fibers. Whole muscle strength, velocity, and power were measured for knee extension and double leg press. RESULTS: Men had greater whole muscle strength, power, and velocity compared with women. Studied were 274 type I and 33 type IIa single fibers. No significant sex differences were found for fiber size, Po, specific force, Vo, power, or specific power in type I or IIa fibers. CONCLUSIONS: Single muscle fiber quality in older women is equivalent to that in older men and can not explain the differences seen in whole muscle strength, power, or function.

Physical activity-mediated functional recovery after spinal cord injury: potential roles of neural stem cells.

As data elucidating the complexity of spinal cord injury pathophysiology emerge, it is increasingly being recognized that successful repair will probably require a multifaceted approach that combines tactics from various biomedical disciplines, including pharmacology, cell transplantation, gene therapy and material sciences. Recently, new evidence highlighting the benefit of physical activity and rehabilitation interventions during the post-injury phase has provided novel possibilities in realizing effective repair after spinal cord injury. However, before a comprehensive therapeutic strategy that optimally utilizes the benefits of each of these disciplines can be designed, the basic mechanisms by which these various interventions act must be thoroughly explored and important synergistic and antagonistic interactions identified. In examining the mechanisms by which physical activity-based functional recovery after spinal cord injury is effected, endogenous neural stem cells, in our opinion, engender a potentially key role. Multipotent neural stem cells possess many faculties that abet recovery, including the ability to assess the local microenvironment and deliver biofactors that promote neuroplasticity and regeneration, as well as the potential to replenish damaged or eradicated cellular elements. Encouragingly, the functional recovery owing to physical activity-based therapies appears relatively robust, even when therapy is initiated in the chronic stage of spinal cord injury. In this article, we review experimental outcomes related to our hypothesis that endogenous neural stem cells mediate the functional recovery noted in spinal cord injury following physical activity-based treatments. Overall, the data advocates the incorporation of increased physical activity as a component of the multidimensional treatment of spinal cord injury and underscores the critical need to employ research-based mechanistic approaches for developing future advances in the rehabilitation of neurological injury and disorders.

Preservation of in vitro muscle fiber function in dermatomyositis and inclusion body myositis: a single fiber study.

Five patients with untreated dermatomyositis, five with inclusion body myositis, and 16 healthy elderly volunteer subjects (controls) underwent open (dermatomyositis and inclusion body myositis) or percutaneous (controls) muscle biopsy. Biopsied muscles included deltoid, biceps and vastus lateralis. Chemically skinned single muscle fibers were activated with Ca(+2); the slack test was performed to determine maximal unloaded shortening velocity (Vo). Parameters measured include single fiber cross sectional area, maximal force, specific force and Vo. 429 Type I and 94 Type IIA fibers were studied. Cross sectional area and maximal force were greater in inclusion body myositis than dermatomyositis or control for Type I and IIA fibers. Specific force of Type I fibers was similar in inclusion body myositis and dermatomyositis but greater than in controls. Vo was greater in Type I, but not IIA, fibers in dermatomyositis compared with inclusion body myositis and controls. The force and velocity generating capacity of single muscle fibers is preserved in patients with dermatomyositis and inclusion body myositis suggesting that dysfunction of the contractile proteins does not contribute to clinical muscle weakness.

IKKbeta/NF-kappaB activation causes severe muscle wasting in mice.

Muscle wasting accompanies aging and pathological conditions ranging from cancer, cachexia, and diabetes to denervation and immobilization. We show that activation of NF-kappaB, through muscle-specific transgenic expression of activated IkappaB kinase beta (MIKK), causes profound muscle wasting that resembles clinical cachexia. In contrast, no overt phenotype was seen upon muscle-specific inhibition of NF-kappaB through expression of IkappaBalpha superrepressor (MISR). Muscle loss was due to accelerated protein breakdown through ubiquitin-dependent proteolysis. Expression of the E3 ligase MuRF1, a mediator of muscle atrophy, was increased in MIKK mice. Pharmacological or genetic inhibition of the IKKbeta/NF-kappaB/MuRF1 pathway reversed muscle atrophy. Denervation- and tumor-induced muscle loss were substantially reduced and survival rates improved by NF-kappaB inhibition in MISR mice, consistent with a critical role for NF-kappaB in the pathology of muscle wasting and establishing it as an important clinical target for the treatment of muscle atrophy.

Skeletal muscle fiber function and rate of disease progression in amyotrophic lateral sclerosis.

The contractile properties of single muscle fibers reflect the functional status of muscle at the cellular level and have not been described in amyotrophic lateral sclerosis (ALS). Chemically skinned single muscle fibers (n = 173), obtained by needle biopsy from six men with ALS, were activated with Ca(2+), allowing maximal force measurements and specific force (SF) estimates. Maximum unloaded shortening velocity (V(o)) was determined using the slack test. The results were compared with muscle from healthy controls. Markers of disease progression included rate of change of ALS functional rating scale score, rate of change of forced vital capacity, and disease duration. Compared with controls, ALS patients had decreased whole muscle SF (measured by a combination of computerized tomography and isokinetic testing) but normal single fiber SF. The V(o) was greater for type I fibers in ALS. Patients with slower disease progression had increased single fiber size and a high percentage of hybrid fibers (expressing multiple myosin heavy chain isoforms). A needle biopsy obtained at the time of ALS diagnosis may assist with predicting rate of disease progression.

Longitudinal changes in body composition in older men and women: role of body weight change and physical activity.

BACKGROUND: Estimates of body-composition change in older adults are mostly derived from cross-sectional data. OBJECTIVE: We examined the natural longitudinal patterns of change in fat-free mass (FFM) and fat mass (FM) in older adults and explored the effect of physical activity, weight change, and age on these changes. DESIGN: The body composition measured by hydrodensitometry and the level of sports and recreational activity (SRA) of 53 men and 78 women with a mean (+/-SD) initial age of 60.7 +/- 7.8 y were examined on 2 occasions separated by a mean (+/-SD) time of 9.4 +/- 1.4 y. RESULTS: FFM decreased in men (2.0% per decade) but not in women, whereas FM increased similarly in both sexes (7.5% per decade). Levels of SRA decreased more in men than in women over the follow-up period. Baseline age and level of SRA were inversely and independently associated with changes in FM in women only. Neither age nor level of SRA was associated with changes in FFM in men or women. Weight-stable subjects lost FFM. FFM accounted for 19% of body weight in those who gained weight, even in the presence of decreased levels of SRA. Loss of FFM (33% of body weight) was pronounced in those who lost weight, despite median SRA levels >4184 kJ/wk. CONCLUSIONS: On average, FM increased; however, the increase in women was attenuated with advancing age. The decrease in FFM over the follow-up period was small and masked the wide interindividual variation that was dependent on the magnitude of weight change. The contribution of weight stability, modest weight gains, or lifestyle changes that include regular resistance exercise in attenuating lean-tissue loss with age should be explored.

Effect of drink pattern and solar radiation on thermoregulation and fluid balance during exercise in chronically heat acclimatized children.

The purposes of this study were to examine the thermoregulatory and body fluid balance responses in chronically heat acclimatized children, i.e., indigenous to a tropical climate, during exercise in four outdoor conditions and the effects of dehydration on their thermoregulatory response. Nine children (age = 13.3 ± 1.9 yr, VO2 max = 45.5 ± 9.2 ml · kg-1 · min-1 ) cycled at 60% VO2 max each under four conditions: sun exposure voluntary drinking (SuVD), sun exposure forced drinking (SuFD), shaded voluntary drinking (ShVD), and shaded forced drinking (ShFD). Exercise sessions consisted of four 20-min exercise bouts alternating with 25-min rest periods. Globe temperature and the WBGT index were higher during SuVD and SuFD compared to ShVD and ShFD (P < 0.05). The change in rectal temperature, metabolic heat production, and heat storage did not differ among the conditions. Total water intake (% IBW) was higher during SuFD (4.1 ± 0.01) and ShFD (3.7 ± 0.1) compared to SuVD (2.1 ± 0.1) and ShVD (1.0 ± 0.1) and during SuVD compared to ShVD (P < 0.05). Sweating rate (L · hr-1 ) was higher during SuFD (0.7 ± 0.1) and ShFD (0.6 ± 0.1) compared to SuVD (0.5 ± 0.1) and ShVD (0.4 ± 0.1) (P < 0.05). Total fluid loss did not differ among conditions (SuVD = 1.7 ± 0.4; SuFD = 1.5 ± 0.4; ShVD = 2.1 ± 0.2; ShFD = 1.3 ± 0.3). Results indicate that when exercising in a tropical climate, chronically heat acclimatized children demonstrate mild voluntary dehydration and adequate heat dissipation. © 1995 Wiley-Liss, Inc.

Diseño de un sistema de vigilancia epidemiológica para los XVII Juegos Deportivos Centroamericanos y del Caribe, Puerto Rico, 1993 / Development of a system for epidemiologic surveillance for the XVII Central American and Caribbean Sport Games, Puerto Rico, 1993

The probability of recording infectious diseases and injuries to the musculoskeletal system during sports events with a large number of participants is very high. From an historical perspective the distribution and trends of diseases that have an impact on public health have been evaluated by means of epidemiological surveillance systems. However, the application of these epidemiological methods to sports medicine is relatively recent. The utilization of an epidemiological surveillance system during sports events with a large number of participating athletes and countries has been reported in a limited number of competitions. In this article we describe the design of a system for epidemiological surveillance utilized during the XVII Central American and Caribbean Sports Games held in Puerto Rico in 1993, as an example of a surveillance system that could be regularly established in this type of event

Descripción de la morbilidad reportada en el sistema de vigilancia epidemiológica de los XVII Juegos Deportivos Centroamericanos y del Caribe, Puerto Rico, 1993 / Description of morbidity notified in the epidemiologic surveillance system of XVII Central American and Caribbean Sport Games, Puerto Rico, 1993

The objective of the epidemiological surveillance system for the XVII Central American and Caribbean Sports Games in 1993 in Puerto Rico was to estimate the morbidity related to infectious diseases and sports injuries during the competitions. In the village hospital a total of 794 medical consultations were reported; 57.7 per cent of the patients were athletes. Among athletes, the rate of consultation was 10.4 for every 100 participants. The consultations were more frequent in males (535, 67.4 per cent ). The analysis by country of origin revealed that the athletes from Guatemala (42, 9.2 per cent ) and Jamaica (35, 7.6 per cent ) used the services more frequently. The incidence of consultations by sport was higher in field hockey (47, 10.3 per cent ), followed by athletics (46, 10 per cent ), and softball (36, 7.9 per cent ). The most frequent diagnoses were injuries--302, 38.04 per cent ; of these 229 (75.8 per cent ) were athletes--,conditions of the respiratory system (180, 22.67 per cent ), problems of the skin and mucous membranes (85, 10.71 per cent ), and problems of the gastrointestinal tract (56, 7.05 per cent ). The severity of the majority of the conditions was mild and required primary care health professionals

Perfil de utilización de los servicios de salud durante los XVII Juegos Deportivos Centroamericanos y del Caribe: Delegación de Puerto Rico, Ponce 1993 / Profile of health services utilization during the XVII Central and Caribbean Sport Games: Delegation of Puerto Rico, Ponce 1993

During the XVII Central American and Caribbean Sports Games held in Ponce in 1993 the health services offered to the Puerto Rico Delegation included medical, dental and psychological assistance, physical therapy and services on the playing field. Information about the use of these services was obtained from the encounter sheets. The Puerto Rican delegation of 750 members had 1,800 encounters with the health team; 612 (34.0 per cent ) individual consults; 896 (54.8 per cent ) physical therapy sessions; 166 (9.2 per cent ) encounters in the sports venues; and 36 (20 per cent ) group therapies. The most common diagnoses were athletic injuries (304; 58.2 per cent ) and diseases of the respiratory system (76; 14.5 per cent ). The most frequent athletic injuries were first degree strains (75; 24.7 per cent ) and tendinitis (73, 24.0 per cent ). This pattern is similar to that observed in other sports games and delegations with mild conditions prevailing. An interdisciplinary work and biopsychosocial approach will be important for the better health and performance of our athletes

Patterns of injuries in athletes evaluated in an interdisciplinary clinic

The pattern of sports injuries appears to be population-specific. The purpose of the present study is to describe 1750 injuries evaluated between April 1988 and April 1994 in our Olympic Training Center Interdisciplinary Sports Injury Clinic. Our patient population included elite and recreational athletes of both sexes between the ages of 7 and 71 years. Males comprised 73 per cent of the patient population and approximately 80 per cent of the injuries corresponded to the 10 to 29 age range. The most frequent sports in males were baseball (21.9 per cent ) and basketball (15.9 per cent ) and in females were track and field (17.1 per cent ) and gymnastics (15.1 per cent ). Most injuries (52 per cent ) were traumatic in nature, chronic (71.6 per cent ), and occurred during training sessions (57.4 per cent ). The most commonly affected anatomical areas were the knee (31.2 per cent ) and shoulder (15.5 per cent ). The most common diagnoses were tendinitis (25.4 per cent ), and first degree strains (11.8 per cent ) and sprains (9.3 per cent ). Finally, treatment strategies included medications (61.0 per cent ), physical therapy (48.9 per cent ), relative rest (35.7 per cent ), and home exercise programs (35.2 per cent ). The variety of musculoskeletal disorders seen in combination with the frequent use of conservative treatment confirms the importance of an interdisciplinary approach to sports injuries