The safety and efficacy of enhanced external counterpulsation as a treatment for angina in patients with aortic stenosis.

BACKGROUND: Comorbid aortic stenosis (AS) has been considered a precaution when applying enhanced external counterpulsation (EECP) to individuals with angina due to concerns about treatment-related hemodynamic changes. HYPOTHESIS: The aim of this study was to determine whether EECP safely reduces symptoms of myocardial ischemia and improves hemodynamics in individuals with AS. METHODS: Forty-three patients with AS (average age, 73 years; 86% male) and 43 comparison patients without AS were chosen from a database of 1327 EECP patients. Canadian Cardiovascular Society (CCS) Functional Angina Classification, diastolic augmentation ratio, and blood pressure were measured at baseline and on completion of the course of EECP. RESULTS: Thirty-five of the 43 patients with AS (81%, 95% CI: 66.6% to 91.6%) and 38 of the 43 without AS (88%, 95% CI: 74.9% to 96.1%) improved in angina class (P < 0.0001). There was no statistical difference between the percentages in patients with and without AS (P = 0.54). CCS angina class outcome was not associated with AS severity (P = 0.55). The percentage of patients with diastolic augmentation ratio ≥1.0 was 16.3% in both groups at baseline and improved to 39.5% in AS patients and 37.2% in non-AS patients after EECP (both P = 0.002). The average decreases in systolic blood pressure in subjects with AS (-15 mm Hg, 95% CI: 11 to 20, P < 0.0001) and without AS (-18 mm Hg, 95% CI: 14 to 22, P < 0.0001) were similar (P = 0.31). No major adverse cardiac events were reported. CONCLUSIONS: Angina patients with AS who undergo EECP had clinically important symptomatic and hemodynamic improvements comparable to their non-AS counterparts.

Enhanced external counterpulsation: a novel therapy for angina.

Improved pharmacological, invasive, and surgical therapies for cardiovascular diseases over the last few decades have led to an increase in life expectancy of individuals with angina. Despite treatment with multiple medications and invasive procedures, these patients remain symptomatic and functionally limited. Enhanced external counterpulsation (EECP) is a safe, noninvasive, well-tolerated, and clinically effective outpatient physical therapy for many patients with refractory angina. Numerous trials demonstrate positive clinical responses to EECP, including reductions in angina and nitrate use, increase in exercise tolerance, and enhanced quality of life. Several mechanisms are thought responsible for the clinical benefits of this therapy. Despite the marked success rates EECP achieves, the treatment remains largely unknown. This review will summarize the current evidence for the use of EECP and spark a better understanding of the potential role of this treatment.

Cardiac rehabilitation: a contemporary review.

Cardiac rehabilitation is increasingly recognized as an essential part of the continuum of care for patients with cardiovascular disease. The discipline has evolved over the last 15 yrs to reflect the importance of targeted initiatives in the management of cardiovascular risk factors. Changes in program scope have broadened to shift the emphasis away from primarily focusing on exercise therapy to embracing a comprehensive secondary prevention strategy addressing the multiple medical, exercise, nutritional, and behavioral factors that place a patient at increased risk of a subsequent cardiac event. Cardiac rehabilitation is a class I recommendation in most current cardiovascular clinical practice guidelines. Despite the large body of literature verifying the sizeable morbidity and mortality benefits, cardiac rehabilitation services are vastly underused. The implementation of recent performance measures will provide the potential to boost referral to, enrollment in, and completion of cardiac rehabilitation programs. The goals, core components, benefits, risks, and outcome measures of cardiac rehabilitation will be reviewed.

Enhanced external counterpulsation: an innovative physical therapy for refractory angina.

The prevalence of refractory angina in the United States is 600,000 to 1.8 million. Improved pharmacological, invasive, and surgical therapies for cardiovascular diseases during the last few decades have led to an increase in life expectancy of such individuals. Despite treatment with multiple medications and invasive procedures, these patients remain symptomatic and functionally limited. Enhanced external counterpulsation (EECP) is a safe, noninvasive, well-tolerated, and clinically effective outpatient physical therapy for many patients with refractory angina. Numerous trials demonstrate positive clinical responses among at least 80% of patients undergoing EECP, including reductions in angina and nitrate use, increases in exercise tolerance, and enhanced quality of life. Several mechanisms, including the promotion of collateral blood flow, improvement in endothelial function, reduction in inflammation, and the production of peripheral training effects similar to exercise, are thought to be responsible for the clinical benefits of this therapy. Despite the marked success rates EECP achieves with appropriately selected patients who have end-stage coronary artery disease, the treatment remains largely unknown, particularly among physiatrists. This review will summarize the current evidence for the use of EECP and spark a better understanding of the potential role of this treatment in cardiac rehabilitation.

Interventions in chronic pain management. 3. New frontiers in pain management: complementary techniques.

UNLABELLED: This self-directed learning module highlights complementary and alternative therapies that are often used by patients seen in the typical physiatric practice. This article contains information on acupuncture and its use to treat low back pain, recent therapeutic approaches to lateral epicondylitis, movement therapies appropriate for the osteoporotic patient, and spa therapies. Scientific literature and standards of clinical practice in these areas have been reviewed to put forth the most recent recommendations regarding these diagnoses and therapeutic interventions. OVERALL ARTICLE OBJECTIVES: (a) To familiarize the physiatrist with complementary techniques that are increasingly popular in the United States and (b) to identify when therapies, such as acupuncture, movement therapies, bodywork, and the like, may be integrated into a comprehensive treatment approach for common physiatric clinical scenarios.

Interventions in chronic pain management. 4. Medications in pain management.

UNLABELLED: This self-directed learning module, which highlights pharmacologic approaches in the management of chronic pain, focuses on both traditional and nontraditional medications. It is part of the study guide on interventions in chronic pain management in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article highlights medication concepts, including the cyclooxygenase-2 inhibitors, opiate management of chronic pain, and neuropathic pain management; and it reviews some nontraditional approaches such as homeopathy and herbal remedies. OVERALL ARTICLE OBJECTIVE: To summarize pharmacologic approaches available for the management of chronic pain syndromes.

Interventions in chronic pain management. 5. Disease-specific issues in chronic pain.

UNLABELLED: This self-directed learning module highlights the importance of applying principles described earlier in the Study Guide to specific diseases encountered by practitioners managing chronic pain in order to administer appropriate treatment. This chapter focuses on several challenging and increasingly common maladies and attempts to delineate rationales for holistic, comprehensive care. OVERALL ARTICLE OBJECTIVE: To explore diagnostic concepts and therapeutic strategies in fibromyalgia syndrome, central pain, multiple sclerosis, complex regional pain syndrome, and postherpetic neuralgia.

Etiologies of failed back surgery syndrome.

STUDY DESIGN: Retrospective chart review. OBJECTIVE: To report the epidemiologic data of nonsurgical and surgical etiologies of failed back surgery syndrome (FBSS) from two outpatient spine practices. SUMMARY OF BACKGROUND DATA: FBSS has been offered as a diagnosis, but this is an imprecise term encompassing a heterogeneous group of disorders that have in common pain symptoms after lumbar surgery. The current literature primarily diagnoses for the various etiologies of FBSS from a surgical perspective. To our knowledge, there is no study that investigates the myriad of surgical and nonsurgical diagnoses from a nonsurgical perspective. METHODS: Specific inclusion and exclusion criteria were developed for a list of 42 nonsurgical and surgical differential diagnoses of FBSS. The determination of which category, surgical or nonsurgical, each diagnosis was placed into depended upon the categorization of those diagnoses in previously published literature on FBSS. Each of the authors reviewed the definitions, and they came to a unanimous agreement on each diagnosis' inclusion and exclusion criteria. Data extraction was then carried out in each of the two involved institutions by using the key words discectomy, laminectomy, and fusion to identify all the patients who had any combination of low back, buttock, or lower extremity pain after lumbar discectomy surgery. These charts were then individually reviewed to extract epidemiologic data. RESULTS: A total of 267 charts were reviewed. One hundred and ninety-seven (197) charts had a complete workup. Of these, 11 (5.6%) had an unknown etiology, and 186 had a known diagnosis. Twenty-three (23) various diagnoses were identified. There was approximately an equal distribution between the incidences of nonsurgical and surgical diagnoses; 44.4% had nonsurgical diagnoses and 55.6% had surgical diagnoses. The most common diagnoses identified were spinal stenosis, internal disc disruption syndrome, recurrent/retained disc, and neural fibrosis. CONCLUSION: FBSS is a syndrome consisting of a myriad of surgical and nonsurgical etiologies. Approximately one half of FBSS patients have a surgical etiology. Approximately 95% of patients can be provided a specific diagnosis.