Evidence-based position paper on Physical and Rehabilitation Medicine (PRM) professional practice on telerehabilitation. The European PRM position (UEMS PRM Section).

INTRODUCTION: The evidence on the utility and effectiveness of rehabilitation interventions delivered via telerehabilitation is growing rapidly. Telerehabilitation is expected to have a key role in rehabilitation in the future. AIM: The aim of this evidence-based position paper (EBPP) is to improve PRM physicians' professional practice in telerehabilitation to be delivered to improve functioning and to reduce activity limitations and/or participation restrictions in individuals with a variety of disabling health conditions. METHODS: To produce recommendations for PRM physicians on telerehabilitation, a systematic review of the literature and a consensus procedure by means of a Delphi process have been performed involving the delegates of all European countries represented in the UEMS PRM Section. RESULTS: The systematic literature review is reported together with the 32 recommendations resulting from the Delphi procedure. CONCLUSIONS: It is recommended that PRM physicians deliver rehabilitation services remotely, via digital means or using communication technologies to eligible individuals, whenever required and feasible in a variety of health conditions in favor of the patient and his/her family, based on evidence of effectiveness and in compliance with relevant regulations. This EBPP represents the official position of the European Union through the UEMS PRM Section and designates the professional role of PRM physicians in telerehabilitation.

Arthrogryposis Multiplex Congenita and the Importance of Orthoses: A Case Report.

Arthrogryposis multiplex congenita (AMC) is a group of conditions characterized by multiple joint contractures. This rare disorder causes stiffness of joints, limiting the range of motion and negatively impacting activities of daily living (ADL). This case reports a 45-year-old male with AMC who was referred to physical medicine and rehabilitation (PMR). He had a limited range of movement in multiple joints and global muscle weakness. However, ADL were feasible, including walking. The patient had an unsteady barefoot gait, causing claudication, which improved significantly with adapted shoes. The primary goal of treatment is to improve the quality of life (QoL), and proper management should be promptly initiated. AMC requires a multidisciplinary approach to care with three mainstays of treatment: rehabilitation, orthoses, and corrective surgeries. Patients should be followed up periodically by their family doctors, and PMR evaluations and rehabilitation should be provided as needed. An orthopedic surgery consultation may be required for surgical interventions to provide optimal outcomes and augment the QoL.

Selection among site-dependent structurally constrained substitution models of protein evolution by approximate Bayesian computation.

MOTIVATION: The selection among substitution models of molecular evolution is fundamental for obtaining accurate phylogenetic inferences. At the protein level, evolutionary analyses are traditionally based on empirical substitution models but these models make unrealistic assumptions and are being surpassed by structurally constrained substitution (SCS) models. The SCS models often consider site-dependent evolution, a process that provides realism but complicates their implementation into likelihood functions that are commonly used for substitution model selection. RESULTS: We present a method to perform selection among site-dependent SCS models, also among empirical and site-dependent SCS models, based on the approximate Bayesian computation (ABC) approach and its implementation into the computational framework ProteinModelerABC. The framework implements ABC with and without regression adjustments and includes diverse empirical and site-dependent SCS models of protein evolution. Using extensive simulated data, we found that it provides selection among SCS and empirical models with acceptable accuracy. As illustrative examples, we applied the framework to analyze a variety of protein families observing that SCS models fit them better than the corresponding best-fitting empirical substitution models. AVAILABILITY AND IMPLEMENTATION: ProteinModelerABC is freely available from https://github.com/DavidFerreiro/ProteinModelerABC, can run in parallel and includes a graphical user interface. The framework is distributed with detailed documentation and ready-to-use examples.

Perfis de envolvimento parental no futebol juvenil: Um estudo com jovens atletas / Perfiles de participación de los padres en el fútbol juvenil: Un estudio con atletas jóvenes / Parental involvement profiles in football: A study with young players

Este estudo analisou as diferenças na perceção dos atletas acerca dos comportamentos parentais, considerando também a importância do escalão desportivo dos atletas. Além disso, foi analisado se diferentes perfis de envolvimento parental, segundo a avaliação dos atletas aos seus pais, correspondiam a diferenças na orientação motivacional e na perceção de rendimento dos jovens atletas. Participaram no estudo 292 atletas do sexo masculino com idades compreendidas entre os 12 e 19 anos (M = 15.0; DP = 1.5), praticantes de futebol no campeonato nacional. Foram aplicados três instrumentos, (1) Questionário de Comportamentos Parentais no Desporto; (2) Escala de Objetivos de Realização no Desporto Juvenil; (3) Questionário de Perceção de Rendimento Desportivo. Os resultados indicaram (a) diferenças na perceção de comportamentos do pai e da mãe separadamente, sendo que, a perceção dos atletas variou em função do seu escalão desportivo; e (b) a orientação motivacional e a perceção de rendimento variaram em função do perfil de envolvimento parental percebido. Em suma, os resultados demonstram a importância do envolvimento parental no desporto juvenil, devendo este fator ser considerado pelos profissionais que intervêmjunto dos jovens atletas.(AU)

Este estudio analizó las diferencias en la percepción de los atletas sobre los comportamientos de sus padres, considerando también la importancia del nivel deportivo de los atletas. Además, se analizó si los diferentes perfiles de participación de los padres, según la evaluación de los deportistas sobre sus padres, se correspondían con diferencias en la orientación motivacional y en la percepción del rendimiento de los jóvenes deportistas. Participaron del estudio 292 atletas masculinos con edades entre 12 y 19 años (M = 15,0; SD = 1,5), futbolistas del campeonato nacional. Se aplicaron tres instrumentos, (1) Cuestionario de Conductas Parentales en el Deporte; (2) Escala de Metas de Logro en Deportes Juveniles; (3) Cuestionario de Percepción del Rendimiento Deportivo. Los resultados indicaron: (a)diferencias en la percepción de los comportamientos del padre y de la madre por separado, y la percepción de los deportistas varió según su nivel deportivo; e (b)la orientación motivacional y la percepción de rendimiento varió según el perfil de participación parental percibida. En resumen, los resultados demuestran la importancia de la participación de los padres en el deporte juvenil, y este factor debe ser considerado por los profesionales que trabajan con jóvenes deportistas.(AU)

This study analysed the differences in athletes’ perception of parental behaviours, considering the importance of athletes’ age category. It was also verified if different parental involvement profiles, according to athletes’ evaluation of their parents’ behaviours, corresponded to differences in motivational orientation and in performance perception of the young athletes. The study included 292 male athletes, aged between 12 and 19 years old (M = 15.0; DP = 1.5), playing football in the national championship. Three instruments were used: (1) Parental Behaviours in Sports Questionnaire; (2) Achievement goal scale for youth sport; (3) Sport Performance Perception Questionnaire. The results indicated: (a)differences in the perception of father’s and mother’s behaviours, separately, and these differences changed according to athletes’ age category; and (b)motivational orientation and performance perception varied according to the perceived parental involvement profile. In sum, the results demonstrate the importance of parental behaviours in youth sports and this aspect should be considered by professionals who work with young athletes.(AU)

Post-stroke dysphagia: Clinical characteristics and evolution in a single-primary stroke center.

BACKGROUND: Dysphagia is a common manifestation after stroke and seems to play a major role in clinical and functional outcomes. OBJECTIVES: To identify clinical predictors of higher degrees of dysphagia, as well as assess its burden in our hospital, in order to understand how to improve the approach to this symptom. METHODS: We included 311 patients admitted in an acute stroke unit in a year-long period. The relationship of dysphagia with different outcomes, both in acute phase and within the first year after stroke, were investigated. RESULTS: Using the Pearson Correlation Coefficient, NIHSS score at admission was positively correlated with the degree of dysphagia (r = 0,783; p < 0,001) and total anterior circulation infarcts and age (> 70 years) were also associated with higher risk of dysphagia (p < 0.001). During hospitalization both respiratory infections and mortality occurred at significantly higher rates for dysphagic patients (p < 0.001) and we observed an increasing trend towards a higher mortality rate, the higher the degree of dysphagia. These patients stayed longer in the stroke unit, with less chance to be discharged home and more frequently transferred to inpatient rehabilitation care. One year after admission, dysphagic patients were more frequently readmitted due to pneumonia and we observed a higher mortality rate compared to patients without dysphagia (p < 0.001). CONCLUSION: The presence of the above-mentioned dysphagia predictive factors should alert us to the need for an early approach, starting in the stroke unit, but also after discharge, taking into account its impact on clinical outcomes, mortality and healthcare costs.

Multidisciplinary rehabilitation in intensive care for COVID-19: randomised controlled trial.

Coronavirus disease 2019 (COVID-19) has led to an increasing number of patients in intensive care units (ICUs). The size of this post-ICU cohort will be unprecedented, with many patients vulnerable to post-intensive care syndrome. We analysed the respiratory and functional effects of a multidisciplinary rehabilitation programme on functional performance, in patients hospitalised in the ICU due to COVID-19. We conducted a randomised controlled clinical trial. 96 patients who fulfilled the eligibility criteria were randomised into control or intervention group. The control group received standard of care in the ICU, and the intervention group received a functional and respiratory rehabilitation protocol that included medical, nursing, physiotherapy and occupational therapy interventions. At discharge, the intervention group showed significantly better muscular strength and respiratory capacity, and significantly fewer days of hospitalisation (12.90±5.8 versus 15.60±6.7 days, p=0.037). At the 4- and 12-week follow-up, we applied our main outcome measure, the 6-min walk test (6MWT). The intervention group had significantly better results than the control group on the 6MWT at the 4-week follow-up (604±67 versus 571±57 m, p=0.018) and at the 12-week follow-up (639±53 versus 611±67 m, p=0.025). These results support the role of a multidisciplinary rehabilitation programme in COVID-19 patients hospitalised in the ICU and adds evidence that the implementation of rehabilitation programmes in ICUs could result in beneficial outcomes for critically ill patients.

The Portuguese version of the musculoskeletal pain intensity and interference questionnaire for musicians (MPIIQM-Pt): Translation, cultural adaptation, and multicenter validation study in professional orchestra musicians.

OBJECTIVES: We aim to assess the validity and reliability of the Musculoskeletal Pain Intensity and Interference Questionnaire for Musicians (MPIIQM) and to add to its cross-cultural adaptation process by translating, culturally adapting, and validating the MPIIQM into European Portuguese language in the population of Portuguese musicians. METHODS: A Portuguese version of the MPIIQM (MPIIQM-Pt) was created through a process of forward and back translation, pilot testing, and cultural adaptation by expert panel evaluation. The psychometric evaluation was performed in a validation sample of 134 musicians, at baseline and after 7 days. RESULTS: The high degree of internal consistency and the substantial test-retest reliability coefficients were demonstrated for each subscale (α = 0.896 and ICC = 0.997 for "pain intensity," and α = 0.879 and ICC = 0.999 for "pain interference," respectively). Exploratory factor analysis indicated two-factor structure (pain intensity and interference) that explained 75.5% of the variance. Both convergent and divergent validity are well demonstrated, confirming more than 90% of the previously defined hypotheses regarding correlations with other measures. DISCUSSION: MPIIQM-Pt is the first validated questionnaire to evaluate pain among Portuguese musicians. It showed excellent psychometric properties, both in terms of internal consistency, test-retest reliability, factor analysis, and construct validity. Therefore, it is a valid and reliable tool suitable for both research and clinical practice purposes. MPIIQM-Pt will allow the development of more robust studies on pain among musicians and the improved assessment and monitoring of pain in this population, filling an important gap in this field of Pain Medicine.

Relatório Final: A gestão da comunicação interna em unidades funcionais do ACeS Baixo Mondego / Final Report: Management of internal communication in functional units of ACeS Baixo Mondego

Introdução: Relatório de estágio é o culminar da Unidade Curricular em causa, sendo constituído por duas partes: a componente de estágio, englobando a descrição e a reflexão sobre o local, as atividades e as competências de gestão desenvolvidas; e a componente investigativa, com a temática central - a Comunicação Interna dos enfermeiros das Unidades Funcionais do ACeS Baixo Mondego. Esta tópico é abordado na literatura há diversos anos, com uma maior incidência atual, pois uma comunicação fluída e transparente poderá prevenir situações indesejáveis. A responsabilidade principal desta transparência e fluidez é do gestor, pois é fundamental transmitirem e explicarem aos empregados, as prioridades, para compreenderem o que têm de fazer e porquê, tornando-os integrantes do processo. Metodologia: a primeira parte será descritiva, com uma vertente reflexiva, e a segunda parte englobará um estudo de natureza exploratória e a formulação de uma proposta de melhoria contínua, tendo como ponto de partida os dados recolhidos. Objetivos: Realizar um diagnóstico de situação sobre a comunicação interna de cada UF (enfermeiro gestor-enfermeiros) e como comunicam no mesmo Centro de Saúde; Formular um plano de melhoria contínua para dar resposta à problemática, através do modelo PDCA. Resultados: a gestão é um dos pilares de uma organização, e a comunicação interna é uma ferramenta para o progresso da cultura organizacional, promovendo a qualidade e a segurança. O sucesso da comunicação traz melhorias e resultados evidentes na saúde em geral, criando uma rede de apoio à comunidade abrangida, e potenciando a competitividade entre as instituições de saúde.

Clinical and Functional Results of Reverse Total Shoulder Arthroplasty and Postoperative Rehabilitation Protocol.

Purpose This retrospective study aims to analyze the clinical and functional results obtained over a seven-year period of performing reverse total shoulder arthroplasty (RTSA) and the subsequent postoperative rehabilitation protocol. Methods We analyzed data from 80 patients who were evaluated at a preoperative, as well as monthly postoperative outpatient consultation, until the discharge from the rehabilitation program, using Constant Score (CS). Results A comparison of preoperative and postoperative (after rehabilitation protocol) results revealed an improved functional score of absolute CS (20.8 increase), normal relative CS (29.1 increase), and individual relative CS (31.7 increase) with statistical significance (p<0.05). From the analysis of CS subscores, there was a positive evolution of the pain subscore, as well as flexion, abduction, and external rotation combined with abduction range of motion (ROM). Contrarily, there was a negative evolution of the combined internal rotation, extension, and adduction ROM, as well as deltoid muscle strength. No statistically significant correlations were found between age and postoperative CS, as well as between the time interval from surgery to the beginning of outpatient rehabilitation and CS evolution. Conclusion Our study demonstrates that RTSA is an effective therapeutic option that, if combined with a well-structured rehabilitation program, can improve pain, mobility, and upper limb functionality.

Esophageal Bullous Pemphigoid.

Bullous pemphigoid is a rare autoimmune dermatologic disease that usually occurs in the elderly. Mucous membrane lesions occur in about 10-35% of patients and are almost always limited to the oral mucous membrane. Esophageal involvement is very rare (4% of cases) and usually presents with chest pain, dysphagia, and odynophagia, though patients are frequently asymptomatic. We report the case of newly diagnosed bullous pemphigoid in a 76-year-old man with a past medical history of dementia. He presented with cutaneous manifestations but also severe gastrointestinal bleeding due to extensive esophageal involvement. Although bullous pemphigoid is mainly a skin disease, mucous membrane lesions should not be overlooked as they are associated with an even poorer outcome. A high index of suspicion for esophageal involvement is needed as its presentation can be fatal, as with our patient. LEARNING POINTS: Bullous pemphigoid is a rare autoimmune disease that should be suspected in elderly patients with itchy cutaneous lesions.Mucous membrane lesions should always be evaluated, as they are associated with a poor prognosis, even if asymptomatic.Early diagnosis should be the main focus, as steroids, the mainstay of treatment, may not be effective in severe cases.

The Individual Rehabilitation Project as the core of person-centered rehabilitation: the Physical and Rehabilitation Medicine Section and Board of the European Union of Medical Specialists Framework for Rehabilitation in Europe.

To facilitate the interaction between the health professional and the patient, a framework to guide the rehabilitation process is needed. This framework would encompass three interwoven aspects: the rehabilitation management plan, Individual Rehabilitation Project (IRP), and rehabilitation cycle(s). All three framework aspects focus on the patient and on the aim of rehabilitation, i.e. to optimize a person's functioning across the continuum of care. An IRP is a multi-element, person-centered rehabilitation management scheme, in which rehabilitation is generally provided by a multiprofessional team under the leadership of a physical and rehabilitation medicine (PRM) physician, working in an interdisciplinary manner and together with the patient (or proxy). A reference system for operationalizing functioning and standardizing the process is the International Classification of Functioning, Disability and Health (ICF) - for assessing functioning needs, defining rehabilitation goals and outcomes. The objective of this paper is to present the IRP as a framework for rehabilitation in Europe (EUR-IRP). The specific aims are: 1) to introduce the IRP; and 2) to describe the framework components, elements and variables of the IRP. Demonstration projects (case studies) using the EUR-IRP will be conducted. The present paper presents the efforts to date for developing the EUR-IRP, a key part of the action plan of the PRM Section and Board of the European Union of Medical Specialists to implement the ICF systemwide across the care continuum. This paper serves as another step to bring together practice, science and governance in calling for contribution from rehabilitation clinicians and researchers and professional societies in PRM and beyond.

Consequences of the Last Glacial Period on the Genetic Diversity of Southeast Asians.

The last glacial period (LGP) promoted a loss of genetic diversity in Paleolithic populations of modern humans from diverse regions of the world by range contractions and habitat fragmentation. However, this period also provided some currently submersed lands, such as the Sunda shelf in Southeast Asia (SEA), that could have favored the expansion of our species. Concerning the latter, still little is known about the influence of the lowering sea level on the genetic diversity of current SEA populations. Here, we applied approximate Bayesian computation, based on extensive spatially explicit computer simulations, to evaluate the fitting of mtDNA data from diverse SEA populations with alternative evolutionary scenarios that consider and ignore the LGP and migration through long-distance dispersal (LDD). We found that both the LGP and migration through LDD should be taken into consideration to explain the currently observed genetic diversity in these populations and supported a rapid expansion of first populations throughout SEA. We also found that temporarily available lands caused by the low sea level of the LGP provided additional resources and migration corridors that favored genetic diversity. We conclude that migration through LDD and temporarily available lands during the LGP should be considered to properly understand and model the first expansions of modern humans.

Congenital Facial Paralysis Revealing an Aplasic Facial Nerve: A Report of Two Cases.

ABSTRACT: Congenital facial palsy is a rare condition, usually related to a traumatic event during birth or as a feature of a syndrome. In this report, two cases of infants with peripheral facial palsy since birth are described, in which magnetic resonance imaging demonstrated unilateral aplasia of the facial nerve. There are only a few cases with similar findings described in the literature. A multidisciplinary approach is recommended to provide the best care. Although no reinnervation of the facial muscles is likely to occur, rehabilitative therapies may be valuable as complementary treatments.

Liver and COVID-19: From care of patients with liver diseases to liver injury.

The global pandemic of coronavirus disease 2019 (COVID-19) changed dramatically all priorities on medical society and created several challenges for clinicians caring for patients with liver diseases. We performed a comprehensive review about how COVID-19 can affect the liver, the influence of liver diseases on the risk of developing severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and COVID-19 severity and also some strategies to overcome all the challenges clinicians have to face in the management of patients with liver diseases in a period of time when all the focus turned on COVID-19. We analyze the relationship between COVID-19 and non-alcoholic fatty liver disease, alcoholic liver disease, viral hepatitis, autoimmune liver disease, cirrhosis, hepatocellular carcinoma and liver transplantation, as well as the approach to SARS-CoV-2 vaccination.

Role of thermography in the assessment of temporomandibular disorders and other musculoskeletal conditions: A systematic review.

The aim of this review was to evaluate whether thermal imaging may constitute a reliable assessment method of musculoskeletal and temporomandibular disorders (TMD/MSD). A systematic review was conducted in the Pubmed, Scopus, Cochrane library, Web of Science, and Lilacs databases. The search terms were "musculoskeletal disorders,""temporomandibular disorders,""infrared thermography,""thermography," and "infrared imaging." The inclusion criteria were: studies published between January 1985 and January 2021, performed in humans, with sample size equal or greater than 20 patients, written in English, Portuguese, French and/or Spanish, and full text available. The exclusion criteria were: systematic reviews, case studies, and/or studies focused on pathologies beyond the review's domain. The risk of bias was evaluated using CASP 2018. A total of 2032 articles were retrieved. Of these, 25 studies met the inclusion criteria and were included to withdraw the following information: title, type of study, first author and year of publication, objective, number of participants, comparisons, and principal conclusions. No RCT were found. Despite some disparity, points of convergence among the majority of authors could be found. In general, healthy individuals show subtle thermal differences between contralateral homolog areas. Concerning orofacial structures, unilateral symptomatic individuals may show thermal differences equal or greater than 0.4°C. Infrared thermography accuracy in diagnosing TMD/MSD is still considered low to moderate. Despite some limitations, IRT might constitute a valuable supporting diagnostic tool in the medical field of TMD and MSD.

Therapeutic respiratory and functional rehabilitation protocol for intensive care unit patients affected by COVID-19: a structured summary of a study protocol for a randomised controlled trial.

OBJECTIVES: The primary objective of the presented study is to analyze the respiratory and functional effects of a rehabilitation program in patients affected by hospitalization in Intensive Care Unit (ICU) due to COVID-19, in comparison with the group treated with standard of care, at discharge endpoint. The secondary objectives of the presented study are to evaluate different outcomes of the rehabilitation program in comparison to standard of care regarding: functional performance at 4-week and 12-week post- discharge mark; health-related quality of life, the impact on the health services (namely days of hospitalization), the cost-effectiveness of the intervention proposed. TRIAL DESIGN: This is a randomized, controlled, double-blind, double-arm clinical trial of treatment, with an allocation ratio 1:1 and framework of superiority. PARTICIPANTS: The study will be conducted at Centro Hospitalar Entre Douro e Vouga, Santa Maria da Feira, Portugal. Potential participants will be adult patients (≥18 years old) hospitalized in ICU with respiratory insufficiency due to COVID-19, who are referred to respiratory and functional rehabilitation. Only patients approved by physical rehabilitation doctors to perform respiratory and functional rehabilitation will be considered potential participants. To be eligible for inclusion participants must have been independent in their activities of daily living before the onset of critical illness (verbal statement by their proxy) and have to meet the safety criteria defined by the Portuguese Society of Physical Rehabilitation Medicine. INTERVENTION AND COMPARATOR: Both groups will receive usual medical and nursing care in the ICU, which involves assessment and treatment of the respiratory system and may include positioning, hyperinflation techniques and suctioning. The physical function of the patient is assessed, and active bed exercises and mobility are encouraged as soon as possible and may include sitting out of bed. The intervention group will receive a functional and respiratory multidisciplinary rehabilitation protocol (that includes medical, nursing, physiotherapy and occupational therapy interventions) during their entire hospital stay. After reassurance that the patients fulfil the safety criteria, they will initiate the rehabilitation protocol, individualized to each patient based on the clinical status. The rehabilitation interventions and exercises implemented will be consistent with recommendations from the Portuguese Society of Physical Rehabilitation Medicine. The intervention will occur 6 days per week (Monday to Saturday), fifteen minutes, twice per day for each participant. Throughout all activities, progression will be increased successively, depending on the individual's tolerance and stability. After discharge, the intervention group will continue with rehabilitation exercises, prescribed by physical rehabilitation doctors. These exercises are designed for the patient to do at home, and then report their execution to rehabilitation nurses through teleconsultation, until 12 weeks after ICU discharge. MAIN OUTCOMES: Baseline descriptive data collection will include age, sex, comorbidities and date of admission to ICU. The need of mechanical ventilation and length of use, as well as the need for oxygen therapy, length of ICU stay (days/hours), incidence of ICU readmission, discharge destination and survival will also be recorded. Prior to intervention, every two days and at discharge, participants will be evaluated using the following scales: Glasgow Coma Scale, Richmond Agitation Sedation Scale, Chelsea Critical Care Physical Assessment, 5 standardized questions for cooperation, Medical Research Council Sum-Score, Handgrip strength test and Medical Research Council dyspnea scale. At discharge, Borg Rating of Perceived Exertion will be evaluated. The primary outcome measure will be functional capacity using the 6-Minute Walk Test, and it will be measured at discharge and at the 4-week and 12-week mark. Medical Research Council Sum-Score, Handgrip strength test, Medical Research Council dyspnea scale and Borg Rating of Perceived Exertion will also be re-evaluated at the 4-week and 12-week mark. The health related quality of life will also be used as an outcome measure, using the 12-Item Short Form Survey, at 12 weeks of follow-up. RANDOMISATION: Participants will be divided into two groups, standard care and intervention, by means of balanced randomization at a 1:1 ratio using blocks of 10 participants. The randomization sequence is going to be created using a free software ( http://www.randomized.org/ ). In order to ensure the confidentiality of the randomisation sequence, this process will be conducted by an assessor external to the study. BLINDING (MASKING): The evaluators in the study will be blinded during the entire process. The evaluators will be unaware of the study objectives and the randomized distribution of patients to study groups and will not have access to the randomization sequence. Although blinding for patients will not be possible to achieve completely, subjects will be unaware of other treatment modalities, and they will not know if they belong to the intervention or standard group. As for the treating physiotherapists and ICU staff, blinding will not be possible to achieve, but they will not be responsible for assessing outcomes. NUMBERS TO BE RANDOMISED (SAMPLE SIZE): We plan to randomise 40 participants to each group. 80 participants in total. TRIAL STATUS: This is the second and definitive protocol version, dated from 26th February 2021. Recruitment started on 8th March 2021. Participants will be recruited between March 8, 2021, and June 8, 2021. Study completion is expected to be October 2021. TRIAL REGISTRATION: ReBEC RBR-7rvhpq9 . Registry name: The effect of rehabilitation in hospitalized COVID-19 patients. Registered on 17 March 2021.Retrospectively registered. FULL PROTOCOL: "The full protocol is attached as an additional file, accessible from the Trials website (Additional file 1). In the interest in expediting dissemination of this material, the familiar formatting has been eliminated; this Letter serves as a summary of the key elements of the full protocol".

Portuguese multidisciplinary recommendations for non-pharmacological and non-surgical interventions in patients with rheumatoid arthritis.

BACKGROUND: Patients with rheumatoid arthritis (RA) report significant levels of disease impact, which are improved, but not fully abrogated by immunosuppressive therapy, even when remission is achieved. This imposes the need for adjuvant interventions targeting the uncontrolled domains of disease impact. Non-pharmacological interventions are widely used for this purpose, but they have not been the object of professional recommendations or guidelines. OBJECTIVE: To propose multidisciplinary recommendations to inform clinical care providers regarding the employment of non-pharmacological and non-surgical interventions in the management of patients with RA. METHODS: The EULAR standardized operating procedures for the development of recommendations were followed. First, a systematic literature review was performed. Then, a multidisciplinary Technical Expert Panel (TEP) met to develop and discuss the recommendations and research agenda. For each developed recommendation i) the level of evidence and grade of recommendation were determined, and ii) the level of agreement among TEP members was set. A recommendation was adopted if approved by ≥75% of the TEP members, and the level of agreement was considered high when ≥8. All relevant national societies were included in this construction process to attain their endorsement. RESULTS: Based on evidence and expert opinion, the TEP developed and agreed on five overarching principles and 12 recommendations for non-pharmacological and non-surgical interventions in patients with RA. The mean level of agreement between the TEP members ranged between 8.5 and 9.9. The recommendations include a broad spectrum of intervention areas, such as exercise, hydrokinesiotherapy, psychological interventions, orthoses, education, general management of comorbidities, among others; and they set the requirements for their application. CONCLUSIONS: These recommendations are based on the consensus judgment of clinical experts from a wide range of disciplines and patients' representatives from Portugal. Given the evidence for effectiveness, feasibility and safety, non-pharmacological and non-surgical interventions should be an integral part of standard care for people with RA. It is hoped that these recommendations should be widely implemented in clinical practice. The target audience for these recommendations includes all health professionals involved in the care of patients with RA. The target patient population includes adult Portuguese people with RA.

Evaluating Causes of Current Genetic Gradients of Modern Humans of the Iberian Peninsula.

The history of modern humans in the Iberian Peninsula includes a variety of population arrivals sometimes presenting admixture with resident populations. Genetic data from current Iberian populations revealed an overall east-west genetic gradient that some authors interpreted as a direct consequence of the Reconquista, where Catholic Kingdoms expanded their territories toward the south while displacing Muslims. However, this interpretation has not been formally evaluated. Here, we present a qualitative analysis of the causes of the current genetic gradient observed in the Iberian Peninsula using extensive spatially explicit computer simulations based on a variety of evolutionary scenarios. Our results indicate that the Neolithic range expansion clearly produces the orientation of the observed genetic gradient. Concerning the Reconquista (including political borders among Catholic Kingdoms and regions with different languages), if modeled upon a previous Neolithic expansion, it effectively favored the orientation of the observed genetic gradient and shows local isolation of certain regions (i.e., Basques and Galicia). Despite additional evolutionary scenarios could be evaluated to more accurately decipher the causes of the Iberian genetic gradient, here we show that this gradient has a more complex explanation than that previously hypothesized.