Cost analysis of early rehabilitation after stroke in comprehensive cerebrovascular centres in the Czech Republic.

OBJECTIVES: The paper analyses real-world data on cost of treatment in patients after stroke hospitalized in early rehabilitation units within comprehensive stroke centres in the Czech Republic. This is the first study of the kind in the Czech Republic, while such information is extremely rare worldwide. Stroke treatment witnessed a dramatic development in the last years, when the main progress was due to establishment of specialized (comprehensive) stroke units incorporating also early rehabilitation. There is a general agreement among clinicians that early rehabilitation is beneficial for patients after stroke. METHODS: Costs of early rehabilitation after stroke were calculated by the micro-costing method alongside a pragmatic study in three Czech hospitals. Patients were transferred to specialized early rehabilitation units usually on 7th to 14th day after stroke onset and received four hours of interprofessional rehabilitation per day. RESULTS: The analysis of data collected during the prospective observational research of 87 patients proved significant differences between patients. The average costs of hospitalization were determined to be CZK 5,104 (EUR 194) per one day of intensive rehabilitation in seriously affected patients early after stroke. These costs differed significantly between hospitals (p-value < 0.001); the structure of direct costs was quite stable, though. About 60% of these costs were due to nursing and overhead, while no more than 15% were consumed by therapists. CONCLUSIONS: The treatment of patients after stroke in specialized stroke units proved to be beneficial for the patients increasing the number of those re-integrated in family and community life.

Ulnar Neuropathy at the Elbow: From Ultrasound Scanning to Treatment.

Ulnar neuropathy at the elbow (UNE) is commonly encountered in clinical practice. It results from either static or dynamic compression of the ulnar nerve. While the retroepicondylar groove and its surrounding structures are quite superficial, the use of ultrasound (US) imaging is associated with the following advantages: (1) an excellent spatial resolution allows a detailed morphological assessment of the ulnar nerve and adjacent structures, (2) dynamic imaging represents the gold standard for assessing the ulnar nerve stability in the retroepicondylar groove during flexion/extension, and (3) US guidance bears the capability of increasing the accuracy and safety of injections. This review aims to illustrate the ulnar nerve's detailed anatomy at the elbow using cadaveric images to understand better both static and dynamic imaging of the ulnar nerve around the elbow. Pathologies covering ulnar nerve instability, idiopathic cubital tunnel syndrome, space-occupying lesions (e.g., ganglion, heterotopic ossification, aberrant veins, and anconeus epitrochlearis muscle) are presented. Additionally, the authors also exemplify the scientific evidence from the literature supporting the proposition that US guidance is beneficial in injection therapy of UNE. The non-surgical management description covers activity modifications, splinting, neuromobilization/gliding exercise, and physical agents. In the operative treatment description, an emphasis is put on two commonly used approaches-in situ decompression and anterior transpositions.

Ultrasound-guided perineural vs. peritendinous corticosteroid injections in carpal tunnel syndrome: a randomized controlled trial.

BACKGROUND: Corticosteroid injections are proven to be effective in the management of carpal tunnel syndrome (CTS); however, the optimal injection site still remains unclear. AIM: The aim of this study is to compare the efficacy of perineural vs. peritendinous target sites for corticosteroid injection in CTS. DESIGN: A randomized, single-blind, controlled trial. SETTING: Outpatients, tertiary care center. POPULATION: Forty-six patients were equally randomized into two intervention groups as group A (18 female and five male patients; mean age: 50.0±15.9 years; mean symptom duration: 5.9±3.3 months) and group B (19 female, four male patients; mean age: 54.3±15.0 years; mean symptom duration: 5.9±4.7 months). METHODS: Methylprednisolone acetate (40 mg) and 1 mL of 1% trimecaine hydrochloride was injected next to the median nerve (group A) or among flexor tendons away from the nerve (group B) under ultrasound (US) guidance. The visual analogue scale was used as the primary outcome measure, and the symptom severity scale and functional status scale of the Boston Carpal Tunnel Questionnaire were used as the secondary subjective outcome measures. Two-point discrimination, grip strength, cross-sectional area, and distal motor latency were assessed as objective outcome measures. The data were collected at baseline and at 2, 6 and 12 weeks after the injection. RESULTS: Both groups showed improvement in subjective and objective measures at 2 weeks following the injection - also maintained up to 12 weeks during the follow-up (P<0.05). However, no difference was observed between the two groups (P<0.05). No serious adverse effects were observed in either group. CONCLUSIONS: Both intervention techniques seem to be effective and safe in the conservative treatment of CTS. CLINICAL REHABILITATION IMPACT: Based on this study results, it might be noteworthy that physicians can opt for perineural or peritendinous injections without compromising the treatment efficacy and safety. Herewith, US guidance is, for sure, necessary for performing safe and accurate injections.

Ultrasound Imaging and Guidance in Common Wrist/Hand Pathologies.

ABSTRACT: Wrist/hand pain is a prevalent musculoskeletal condition with a great spectrum of etiologies (varying from overuse injuries to soft tissue tumors). Although most of the anatomical structures are quite superficial and easily evaluated during physical examination, for several reasons, the use of ultrasound imaging and guidance has gained an intriguing and paramount concern in the prompt management of relevant patients. In this aspect, the present review aims to illustrate detailed cadaveric wrist/hand anatomy to shed light into better understanding the corresponding ultrasonographic examinations/interventions in carpal tunnel syndrome, trigger finger, de Quervain tenosynovitis, rhizarthrosis, and the radiocarpal joint arthritis. In addition, evidence from the literature supporting the rationale why ultrasound guidance is henceforth unconditional in musculoskeletal practice is also exemplified.

Early post-stroke rehabilitation for upper limb motor function using virtual reality and exoskeleton: equally efficient in older patients.

AIM OF THE STUDY: To evaluate the effectiveness of virtual reality therapy (VRT) Armeo Spring® upper limb exoskeleton (Armeo), in early post-stroke rehabilitation with a focus on the elderly. CLINICAL RATIONALE FOR THE STUDY: Convalescence from a stroke is a complex process driven by a spontaneous recovery supported by multifactorial activation. Novel technology-based rehabilitation methods are being introduced to support brain plasticity. MATERIALS AND METHODS: Using a randomised controlled study design, participants within 30 days after stroke with arm paresis were, in addition to a daily rehabilitation programme, assigned to an intervention group (45 minutes Armeo IG n = 25; mean age 66.5 years) performing VRT, or to a conventional physiotherapy (45 minutes) control group (Armeo CG, n = 25, mean age 68.1 years). Montreal Cognitive Assessment (MoCA), Functional Independence Measure (FIM) and Fugl Mayer Assessment Upper Extremity Scale (FMA-UE) were performed before and after the three-week therapy with 12 therapeutic sessions. Results of participants < 65 and ≥ 65 years old were compared. RESULTS: Paretic upper arm function improved significantly in both the IG and CG groups, the improvement in FMA-UE was significantly higher in the IG compared to the CG (p = 0.02), and patients ≥ 65 years old presented an equal magnitude of improvement in paretic arm function compared to younger patients. CONCLUSIONS AND CLINICAL IMPLICATIONS: Early post-stroke rehabilitation strategies using, in addition to the daily rehabilitation programme, VRT with visual biofeedback is more effective on upper extremity motor performance than conventional physiotherapy, and the effectiveness does not diminish with patient age. This may be a promising addition to conventional physiotherapy in older stroke patients as well as in younger.

Cost and cost-effectiveness of early inpatient rehabilitation after stroke varies with initial disability: the Czech Republic perspective.

The purpose of this prospective study was to determine whether the cost and cost-effectiveness of early rehabilitation after stroke are associated with the degree of initial disability. The data for cost calculations were collected by the bottom-up (micro-costing) method alongside the standard inpatient care. The total sample included 87 patients who were transferred from acute care to early rehabilitation unit of three participating stroke centers at the median time poststroke of 11 days (range 4-69 days). The study was pragmatic so that all hospitals followed their standard therapeutic procedures. For each patient, the staff recorded each procedure and the associated time over the hospital stay. The cost and cost-effectiveness were compared between four disability categories. The average cost of the entire hospitalization was CZK 114 489 (EUR 4348) with the daily average of CZK 5103 (EUR 194). The cost was 2.4 times higher for the immobile category (CZK/EU: 167 530/6363) than the self-sufficient category (CZK/EUR: 68 825/2614), and the main driver of the increase was the cost of nursing. The motor status had a much greater influence than cognitive status. We conclude that the cost and cost-effectiveness of early rehabilitation after stroke are positively associated with the degree of the motor but not cognitive disability. To justify the cost of rehabilitation and monitor its effectiveness, it is recommended to systematically record the elements of care provided and perform functional assessments on admission and discharge.

Ultrasonographic evaluation of the distal femoral and talar cartilage thicknesses in patients with poliomyelitis: a cross-sectional observational study.

BACKGROUND: Sequelae of poliomyelitis, coupled with asymmetric impairment and weight-bearing, typically alter walking biomechanics which can be associated with the knee and ankle osteoarthritis. AIM: We aimed to investigate whether the distal femoral and talar cartilage thicknesses were different in patients with poliomyelitis. DESIGN: Cross-sectional observational study. SETTING: Outpatients, tertiary care center. POPULATION: Thirty-six patients (12 males, 24 females) with a history of poliomyelitis and 36 age, gender and body mass index similar healthy subjects (11 males, 25 females) were enrolled. Mean values for age, body mass index and age of the poliomyelitis onset were 70.2±4.6 years, 27.2±5.7 kg/m2, and 3.6±2.4 years. METHODS: Visual Analogue Scale (VAS) was used to assess pain. Lower limb muscle strengths were measured by manual muscle testing. The more affected side was identified according to the lower limb manual muscle testing. Bilateral distal femoral cartilage from the lateral femoral condyle, intercondylar area, medial femoral condyle and talar cartilage thicknesses were measured using ultrasound imaging. RESULTS: Among patients, the onset of poliomyelitis was at 3.6±2.4 years of age, and Functional Ambulation Category scores were 5 (3-5). VAS scores were similar between the sides affected more and less by poliomyelitis. All cartilage thicknesses (except the talar cartilage) of the patients were found to be thinner on the more affected side than the less affected side (all P<0.001). The thickness of talar cartilage was thinner compared to control subjects (P<0.001). Among the patients, quadriceps muscle strength was positively correlated with medial condyle (r=0.377, P=0.024), intercondylar area (r=0.399, P=0.016) and lateral condyle (r=0.363, P=0.030) thicknesses. Knee VAS scores were negatively correlated with talar cartilage thicknesses (r=-0.393, P=0.018). CONCLUSIONS: We found a thinning of the distal femoral condyle in the more affected paretic sides of poliomyelitis patients as compared to both those of less affected sides and those of healthy controls. Talar cartilages on both sides of the patients were thinner compared to control subjects. CLINICAL REHABILITATION IMPACT: Our preliminary findings may contribute to the long-term management of patients with long-term poliomyelitis sequelae.

Role of diversity in assembling of rehabilitation teams in Central Europe.

BACKGROUND: Multiprofessional teamwork in physical and rehabilitation medicine (PRM) allows achieving patient-centered goals in accordance with the assumptions of the bio-psycho-social model of functioning. Team composition and methods of collaboration depend of the specificity of goals to be achieved, as well local contextual factors. International comparative studies on rehabilitation teamwork are lacking, despite data on how teams differ between countries are crucial for the process of harmonization of PRM practice across Europe. AIM: To compare models of collaboration within rehabilitation teams in Central Europe. DESIGN: A cross-sectional explorative study. SETTING: The data were collected in Bulgaria, Croatia, Czech Republic, Hungary, Poland, Romania, Slovakia between February and June 2018. POPULATION: PRM physicians. METHODS: An anonymous questionnaire inquiring of rehabilitation teamwork details was spread through national PRM societies, and other organizations associating PRM physicians. An ordered logit regression was applied to analyze the results. RESULTS: Responses were obtained from 455 respondents. Significant differences between the studied countries in the composition of rehabilitation teams and frequencies of team meetings were detected. In the analyzed population of PRM physicians, we found positive associations between the chance of participation in team meetings and working in a hospital, the amount of time devoted to PRM practice, and older age. The chance for patients and caregivers to participate in rehabilitation team meetings was correlated with PRM physician's hospital practice, activity as a PRM teacher, older age and devoting more time to PRM practice. Country specificities of rehabilitation team content were analyzed with regards to local economic, legal, and historical backgrounds, and availability of human resources. Underrepresentation of key professionals (e.g. occupational therapists, orthotists/prosthetists), inadequate distribution of professionals in healthcare and as well as outdated educational systems in some countries may affect the efficacy of the comprehensive care in rehabilitation. CONCLUSIONS: Central European countries differ in rehabilitation teamwork with regard to the contribution of professionals, meeting frequencies, and participation of patients and caregivers. Well-designed studies on teamwork models delineating ways to improve teamwork efficacy are in demand. CLINICAL REHABILITATION IMPACT: Between-country diversity of rehabilitation team content should be considered while planning activities aimed at European harmonization of PRM practice.

The approach of physiatrists to low back pain across Europe.

BACKGROUND: Low back pain (LBP) is the most common type of musculoskeletal pain, thus it is one of the most commonly encountered conditions in Physical and Rehabilitation Medicine. The physicians who are primarily responsible for the nonsurgical management of LBP are physiatrists. OBJECTIVE: The present study aimed to investigate the approaches of physiatrists to low back pain across Europe. Preferences, tendencies, and priorities in the diagnosis, management, and treatment of LBP, as well as the epidemiological data pertaining to LBP in PRM practice were evaluated in this Europe-wide study. METHODS: The study was conducted under the control of the European Society of Physical and Rehabilitation Medicine (ESPRM) Musculoskeletal Disorders Research Committee. A total of 576 physiatrists from most European countries participated in the survey. RESULTS: The results show that physiatrists frequently deal with patients with LBP in their daily practice. Most patients are not referred to other departments and are treated with various conservative methods. Less than one-fifth of patients are primarily referred for surgery. The physiatrists believe that a clear diagnosis to account for cases of low back pain is rarely established. The most common diagnosis is discopathy. History and physical examination remain the most valuable clinical evaluation tools for low back pain according to physiatrists. Less than half the patients require a magnetic resonance imaging. Non-steroidal anti-inflammatory drugs are the most commonly prescribed drugs for low back pain. Exercise, back care information, and physical therapy are the preferred conservative treatments. More than half of the physiatrists offer interventional treatments to patients with low back pain. CONCLUSION: The present study is a preliminary report that presents the attitudes of European physiatrists in the management of low back pain. Further researches are warranted to standardize the conservative management of LBP.

Evidence-based position paper on Physical and Rehabilitation Medicine professional practice for Adults with Acquired Brain Injury. The European PRM position (UEMS PRM Section).

BACKGROUND: Acquired brain injury (ABI) is damage to the brain that occurs after birth caused either by a traumatic or by a nontraumatic injury. The rehabilitation process following ABI should be performed by a multi-professional team, working in an interdisciplinary way, with the aim of organizing a comprehensive and holistic approach to persons with every severity of ABI. This Evidence Based Position Paper represents the official position of the European Union through the UEMS Physical and Rehabilitation Medicine (PRM) Section and designates the professional role of PRM physicians for people with ABI. The aim was to formulate recommendations on the PRM physician's professional practice for persons with ABI in order to promote their functioning and enhance quality of life. METHODS: This paper has been developed according to the methodology defined by the Professional Practice Committee of the UEMS-PRM Section: a systematic literature search has been performed in PubMed and Core Clinical Journals. On the basis of the selected papers, recommendations have been made as a result of five Delphi rounds. RESULTS: The literature review as well as thirty-one recommendations are presented. CONCLUSIONS: The expert consensus is that structured, comprehensive and holistic rehabilitation program delivered by the multi-professional team, working in an interdisciplinary way, with the leadership and coordination of the PRM physician, is likely to be effective, especially for those with severe disability after brain injury.

Effects of a single dose of erythropoietin on motor function and cognition after focal brain ischemia in adult rats.

We tested the influence of erythropoietin (EPO), a basic cytokine in erythropoiesis regulation, on the process of motor function and cognition after focal brain ischemia induced by a local application of endothelin. Endothelin-1 (ET-1) induced short lasting strong vasoconstriction, with described impact on the structure and on the function of neuronal cells. Neurological description of motor function and Morris water maze test (the swimming test is one of most widely used methods for studying cognitive functions in rodents) were used to study the process of learning and memory in three-month-old male albino Wistar rats (n=52). Both tests were performed one week before, and three weeks after ischemia induction (endothelin application on the cortex in the area of a. cerebri media dx.). Experimental group received i.p. injection of EPO (5,000 IU/kg body weight, 10 min before endothelin application). Control group of animals received one i.p. injection of saline at the dose of 1 ml/kg body weight at the same time. Only sham surgery was performed in the third group of animals. Rats with EPO pretreatment before the experimental lesion exhibited significantly better motor and cognitive function then those with saline injection. No significant changes in the motor and cognitive function were found in the third group of rats (sham operated controls).

Functioning and disability in traumatic brain injury.

PURPOSE: To describe functioning and disability in patients with traumatic brain injury (TBI) according to the model endorsed by the International Classification of Functioning Disability and Health (ICF). METHODS: Adult patients with acquired TBI were consecutively enrolled. The Functional Independence Measure (FIM), the WHO Disability Assessment Schedule II (WHO-DAS II) and the ICF checklist were administered in individual sessions. Descriptive analyses were performed to report on FIM and WHO-DAS II scores. ICF categories reported as a problem by more than 20% of patients were described in detail. RESULTS: One hundred patients (66 males, mean age 36.1) were enrolled. Mean WHO-DAS II score was 16.8, mean FIM was 116.5 and 87 ICF categories were selected: 27 Body Functions (mainly mental and movement-related) and Structures, 43 Activities and Participation (mainly connected with mobility) and 17 Environmental Factors. Negligible difference between capacity and performance qualifiers was observed. CONCLUSIONS: The ICF can be successfully implemented in clinical and rehabilitation of patients with TBI, because it enables to describe the variety of problems they encounter: ICF-derived data provide a holistic view of disability and enable the impact of service interventions on functioning and participation, and enable clinicians to tailor intervention according to patient's actual needs.

Functioning and disability in multiple sclerosis.

PURPOSE: To describe functioning and disability in patients with multiple sclerosis (MS) according to the model endorsed by the International Classification of Functioning Disability and Health (ICF). METHODS: Adult patients with MS were consecutively enrolled. The Expanded Disability Status Scale (EDSS), the WHO Disability Assessment Schedule II (WHO-DAS II) and the ICF checklist were administered in individual sessions. Descriptive analyses were performed to report on EDSS and WHO-DAS II scores. ICF categories reported as a problem by more than 20% of patients were described in detail. RESULTS: One hundred patients (70 females, mean age 41.7), 73 with relapsing-remitting MS were enrolled. Mean WHO-DAS II score was 10.6 and 58 ICF categories were selected: 23 Body Functions and Structures, 21 Activities and Participation and 14 Environmental Factors. CONCLUSIONS: The ICF can be successfully implemented in clinical and rehabilitation of patients with MS, because it enables to describe its multiple facets. Little differences between capacity and performance in ICF categories connected with activities of daily living, and presence of technical aids and other environmental factors are reported. On the contrary, in categories related to relationships, performance was worse than capacity thus revealing attitudinal barriers.