Pastoral care and religious support as a part of treatment of religious patient with the severe form of osteoarthritis.

Introduction: Religious needs of patients are consistently being neglected in the clinical medicine. Pastoral care is a religious support which a religious patient receives from priests, chaplains, imams, rabbis or other religious authorities. Religious support, in terms of clinical medicine, is a spiritual support which religious patients obtain from religious and trained medical workers. The aim of this report was to present the effects of pastoral care and religious support in hospital treatment of a 73-year-old patient with the severe form of osteoarthritis. Case report: The 73- year-old, highly religious patient with severe form of osteoarthritis was admitted at the Clinic for Physical Medicine and Rehabilitation, Military Medical Academy in Belgrade, due to heterogeneous problems in the activities of daily living. The patient walked with difficulty using a stick, suffered pain, and was anxious and depressive. In order to objectively demonstrate effects of both pastoral care and religious support in this patient we performed multiple treatment with reversal design, in which the basic treatment consisting of hospital care, pharmacotherapy and physical therapy (the treatment A) was alternatively changed with the treatment that included combination of the basic treatment and religious support provided by religious physiatrist and physiotherapist (the treatment B) or combination of the basic treatment and pastoral care provided by military priest (the treatment C). The treatment A was applied three times and lasted two weeks, every time. Treatments B and C were applied once and lasted three weeks, each. The order of the treatments was: A→B→A→C→A. During the whole treatment period the patient's condition was assessed by several measuring scale: the level of depression by The Hamilton Rang Scale for Depression and The Zung Self Rating Depression Scale; the level of anxiety by The Zung Self Rating Anxiety Scale; the functional capability of patient by The Barthel Index and The Functional Independent Measure. Measuring was carried out on a daily basis. In statistical analysis two nonparametric statistic were used: the percentage of non-overlapping data (PND) and the percentage of data points exceeding the median (PEM). PND and PEM values below 0.7 reflect questionable effectiveness of the treatment. The values between 0.7 and 0.9 reflect moderate effects. The values above 0.9 are considered as a highly effective treatment. The anxiety of the patient was moderately to significantly reduced after introducing religious support (treatment B: mean and mean deviation = 50.1 ± 10.89; variability = 4.598653; mean shift = 0.219626; PND = 0.6; PEM = 0.9) and pastoral care (treatment C: mean and mean deviation = 53.5 ± 5.90; variability = 9.062591; mean shift = 0.207407; PND = 0.9; PEM = 0.9). The patient's depression was reduced after introducing pastoral care (treatment C: mean and mean deviation = 51.3 ± 4.66; variability = 10.99005; mean shift = 0.08881; PND = 0; PEM = 0.9). On the contrary, the patient's functional capability was not significantly improved. Conclusion: In the highly religious patient with severe osteoarthritis pastoral care and religious support, applied along with the standard medical treatment of this condition, produced some beneficial effects on anxiety and depressive mood, but with no significant effect on patient's functional capability.

Diagnostic accuracy of the A-test and cutoff points for assessing outcomes and planning acute and post-acute rehabilitation of patients surgically treated for hip fractures and osteoarthritis.

Background/Aim: The A-test is used in daily clinical practice for monitoring functional recovery of orthopedic patients during early rehabilitation. The aim of this study was to determine the accuracy of A-test and cutoff point at which the test can separate patients with and without functional disability at the end of early rehabilitation. Also, it was important to determine whether A-test has that discriminative ability (and at which cutoff points) in the first days of early rehabilitation in order to have time to plan post acute rehabilitation. Methods: This measurement-focused study was conducted in the Orthopedic Ward during early inpatient rehabilitation (1st−5th day after the operation) of 60 patients with hip osteoarthritis (HO) that underwent arthroplasty and 60 surgically treated patients with hip fracture (HF). For measurements we used the A-test and the University of Iowa Level of Assistance Scale (ILAS) as the gold standard. For statistical analysis we used the receiver operating characteristic (ROC) curve and the area under the curve (AUC) with 95% confidence interval for the results of A-test from the first to the fifth day of rehabilitation, sensitivity, specificity, the rate of false positive and false negative errors, positive and negative predictive value, ratio of positive and negative likelihood ratio, accuracy, point to the ROC curve closest to 0.1 and Youden index for all the cutoff points. Results: The AUC was 0.825 (0.744−0.905) for the first day of rehabilitation, 0.922 (0.872−0.972) for the second day of rehabilitation, 0.980 (0.959−1.000) for the third day of rehabilitation, 0.989 (0.973−1.004) for the fourth day, and 0.999 (0.996−1.001) for the fifth day of rehabilitation. The optimal cutoff for the results of A-test was: 7/8 for the first day, 29/30 for the fourth day, and 34/35 for the fifth day of rehabilitation. On the second and the third day A-test had two cutoff points, the lower point safely separated the patients with functional disability, while the upper point ruled out functional disability. On the 2nd rehabilitation day the cutoff points were 12/13 and 17/18, on the 3rd rehabilitation day cutoff points were 13/14 and 18/19. Conclusion: The A-test has all characteristics of an accurate tool which can be used for separating patients with and without functional disability at all stages of early rehabilitation after surgically treated hip disease or fracture. Based on the results of A-test within the first days of early rehabilitation, it is possible to make a plan for postacute rehabilitation.

Effects of a short-term differently dosed aerobic exercise on maximum aerobic capacity in breast cancer survivors: a pilot study.

BACKGROUND/AIM: Regular physical activity and exercise improves quality of life and possibly reduces risk of disease relapse and prolongs survival in breast cancer survivors. The aim of this study was to evaluate the impact of a 3-week moderate intensity aerobic training, on aerobic capacity (VO2max) in breast cancer survivors. METHODS: A prospective, randomized clinical study included 18 female breast cancer survivors in stage I-IIIA, in which the primary treatment was accomplished at least 3 months before the study inclusion. In all the patients VO2max was estimated using the Astrand's protocol on a bicycle-ergometer (before and after 3 weeks of training), while subjective assessment of exertion during training were estimated by the Category-Ratio RPE Scale. Each workout lasted 21 minutes: 3 minutes for warm-up and cool-down each and 15 min of full training, 2 times a week. The workload in the group E1 was predefined at the level of 45% to 65% of individual VO2max, and in the group E2 it was based on subjective evaluation of exertion, at the level marked 4-6. Data on the subjective feeling of exertion were collected after each training course in both groups. RESULTS: We recorded a statistically significant improvement in VO2max in both groups (E1--11.86%; E2--17.72%), with no significant differences between the groups. The workload level, determined by the percent of VO2max, was different between the groups E1 and E2 (50.47 +/- 7.02% vs 55.58 +/- 9.58%), as well as subjective perception of exertion (in the groups E1 and E2, 11.6% and 41.6% of training, respectively, was graded in the mark 6). CONCLUSION: In our group of breast cancer survivors, a 3-week moderate intensity aerobic training significantly improved the level of VO2max.

Sexual rehabilitation after myocardial infarction and coronary bypass surgery: why do we not perform our job?

BACKGROUND/AIM: There is a perception that in patients with heart diseases in Serbia sexual rehabilitation does not exist. Why do we not perform our job? A kind of resistance to sexual rehabilitation is common for heart disease patients. Prejudices regarding patients' sexuality, fear and limited knowledge are not rare among the members of medical staff. The aim of this study was to assess knowledge on sexual rehabilitation, inner sense during conversation on sexual rehabilitation and quality of sexual life in patients with myocardial infarction (MI) and bypass surgery (BPS). Also, we wanted to assess an opinion of the medical staff members about that. METHODS: We performed a prospective nonrandomized clinical study, which involved 40 participants: ten patients, six partners and twenty four medical staff members. All participants were tested by the self-created questionnaires. The main issues of observation were: knowledge about sexual rehabilitation, quality of sexual life and inner sense during conversation on sexual rehabilitation. The data were analyzed by the Shapiro-Wilk test, Kolmogorov Smirnov test, Mann Whitney Exact test and Fishers Exact test. Statistical significance was set up to p < 0.05. RESULTS: There was a statistically significant difference among the participants regarding an attitude when sexual activity should be resumed after MI or BPS. The members of medical staff had a significantly different opinion about the most important team members responsible for sexual rehabilitation performance. There was a statistically significant difference (p = 0.01) in quality of patient's sexual life after MI or BPS (score: 14.2 +/- 5.5) in relation to conditions before them (score: 21.3 +/- 3.1). The members of medical staff had significantly (P = 0.05) worse inner sense (score: 3.8 +/- 0.7) during and after fulfilling the questionnaires than the patients (score: 4.6 +/- 0.5). CONCLUSION: Ignorance and prejudices are reasons why we do not perform our job.

Pulse low-intensity electromagnetic field as prophylaxis of heterotopic ossification in patients with traumatic spinal cord injury.

BACKGROUND/AIM: Heterotopic ossification (HO) is an important complication of head and spinal cord injuries (SCI). Pulse low-intensity electromagnetic field (PLIMF) therapy increases blood flow to an area of pain or inflammation, bringing more oxygen to that area and helps to remove toxic substances. The aim of this study was to determine the effect of PLIMF as prophylaxis of HO in patients with SCI. METHODS: This prospective random control clinical study included 29 patients with traumatic SCI. The patients were randomly divided into experimental (n=14) and control group (n=15). The patients in the experimental group, besides exercise and range of motion therapy, were treated by PLIMF of the following characteristics: induction of 10 mT, frequency of 25 Hz and duration of 30 min. Pulse low-intensity electromagnetic field therapy started in the 7th week after the injury and lasted 4 weeks. The presence or absence of HO around the patients hips we checked by a plane radiography and Brookers classification. Functional capabilities and motor impairment were checked by Functional Independent Measure (FIM), Barthel index and American Spinal Injury Association (ASIA) impairment class. Statistic analysis included Kolmogorov-Smimrnov test, Shapiro-Wilk test, Mann Whitney Exact test, Exact Wilcoxon signed rank test and Fischer Exact test. Statistical significance was set up to p<0.05. RESULTS: At the end of the treatment no patient from the experimental group had HO. In the control group, five patients (33.3%) had HO. At the end of the treatment the majority of the patients from the experimental group (57.14%) moved from ASIA-A to ASIA-B class. CONCLUSION: Pulse low-intensity electromagnetic field therapy could help as prophylaxis of HO in patients with traumatic SCI.

Avaliação dos efeitos a longo prazo da acupuntura e exercícios terapêuticos em ombro congelado de pacientes com acidente cerebral vascular / Evaluation of long term effects of acupuncture and therapeutic exercises on frozen shoulder in stroke patients

Objetivo do estudo: Determinar como a acupuntura e a terapia com exercícios afetam a função motora e espasmodicidade das mãos de pacientes com acidente cerebral vascular 6 meses após eles terem recebido este tipo de terapia. Métodos: Estudo clínico prospectivo, aleatório e cego de 20 pacientes, com idades entre 60-70 anos, na fase crônica de 6 meses após o AVC. Os sujeitos do estudo foram divididos em dois grupos: Grupo A, o qual foi tratado com acupuntura e terapia de exercícios (AP-ET) 6 meses atrás e Grupo B, o qual foi tratado apenas com terapia de exercícios (ET) 6 meses atrás. A avaliação incluiu uma entrevista ampla e a administração dos estágios de Brunnstrom, a Medida de Independência Funcional (MIF), a Escala Modificada de Ashworth (MAS), o Teste de Funcionalidade das Extremidades Superiores (UEFT), o Registro de Atividade Motora (MAL), a Série de Movimentos ativos e passivos (ROM, pROM), o teste de FUGL-Meyer da função da extremidade superior (FMA), o Questionário de Croft sobre Incapacidade do Ombro (CSDQ) e a Escala Analógica Visual (VAS) de dor. O Teste-t de Gosset foi usado para uma análise estatística. Resultados: As análises mostraram uma diferença estatisticamente significativa nos SCORES do pós-tratamento em comparação com 6 meses após o tratamento com cada grupo de estudo, para todos os parâmetros examinados (p<0.01 em todos os casos) exceto pelo MAS.

Aim of the study: To determine how acupuncture and exercise therapy affect motor function and spasticity on the hands of stroke patients 6 months after they had received this kind of therapy. Methods: Prospective, randomized, single blind clinical study of 20 patients, age 60-70 years, in the chronic phase 6 months after stroke. Subjects were divided into two groups: Group A, which was treated with acupuncture and exercise therapy (AP-ET) 6 months ago and Group B, which was treated with exercise therapy (ET) alone 6 months ago. the assessment included a comprehensive interview and administration of the Brunnstrom?s stages, Functional Independence Measure (FIM), Modified Ashworth Scale (MAS), Upper Extremity Function Test (UEFT), Motor Activity Log (MAL), active and passive Range of Motion (aROM, pROM), Fugl-Meyer test of upper extremity function (FMA), Croft Shoulder Disability Questionnaire (CSDQ) and Visual Analogue Scale (VAS) of pain. The Gosset t-Test was used for the statistical analysis. Results: Analyses showed a statistically significant difference in the post-treatment SCORES as compared to 6 months after treatment within each study group for all parameters examined (p<0.01 in all cases) except for MAS. Analyses showed a statistically significant difference in some parameters in the ET group as compared to the AP-ET group with greater mean values recorded in the AP-ET group for MAS and CSDQ. All other parameters showed no statistical differences between the two different therapy groups 6 months after the therapy. Conclusion: The results confirm the hypothesis that acupuncture and exercise therapy are useful in the treatment of frozen shoulder in stroke patients and that their effects are still present after 6 months of therapy, however, given the small patient population, further studies are needed to verify these results.

The effects of polarized light therapy in pressure ulcer healing.

BACKGROUND/AIM: Neglecting polarized light as an adjuvant therapy for pressure ulcers and methodology distinctions in the trials engaging polarized light are the reasons for many dilemmas and contradictions. The aim of this study was to establish the effects of polarized light therapy in pressure ulcer healing. METHODS: This prospective randomized single-blind study involved 40 patients with stage I-III of pressure ulcer. The patients in the experimental group (E) were subjected, besides polarized light therapy, to standard wound cleaning and dressing. Standard wound cleaning and dressing were the only treatment used in the control group (C). A polarized light source was a Bioptron lamp. Polarized light therapy was applied for six min daily, five times a week, four weeks. The Pressure Ulcer Scale for Healing (PUSH) was used in the assessment of outcome. Statistic analysis included Mann Whitney Test, Fisher Exact Test, Wilcoxon Signed Rank test. RESULTS: There were significant differences between the groups at the end of the treatment regarding the surface of pressure ulcer (E: 10.80 +/- 19.18; C: 22,97 +/- 25,47; p = 0.0005), rank of pressure ulcer (E: 5.90 +/- 2.48; C: 8.6 +/- 1.05; p = 0.0005) and total PUSH score (E: 7.35 +/- 3.17; C: 11.85 +/- 2.35; p = 0,0003). The patients in the experimental group had significantly better values of the parameters monitored than the patients in the control group. CONCLUSION: After a four-week polarized light therapy 20 patients with stage I-III ulcer had significant improvement in pressure ulcer healing, so it could be useful to apply polarized light in the treatment of pressure ulcers.

Pain, functional status, social function and conditions of habitation in elderly unilateraly lower limb amputees.

BACKGROUND/AIM: Few authors are involved in home rehabilitation of amputees or their reintegration into the community. It has been remarked that there is a discontinuity between the phases of the amputee rehabilitation in Serbia. The aim of the study was to establish pain characteristics and functional status of amputees two months after the amputation and to determine their social function and the conditions of their habitation. METHODS: This prospective observation study involved 38 elderly amputees with unilateral lower limb amputations. The patients were tested at the hospital on discharge and at their homes two months after the amputation. Pain intensity and functional status were measured by a visual analogue scale (VAS) and by Functional Independence Measure (FIM). The patients' social function was assessed using the Social Dysfunction Rating Scale (SDRS) and conditions of their habitation by the self-created Scale of Conditions of Habitation (SCH). In statistic analysis we used the Student t test, chi2 test and Analysis of variance (ANOVA). RESULTS: The majority of patients (63%) underwent below knee amputation caused by diabetes (89%). A significant number of patients (84%, chi2 = 17.78; p < 0.01) was not visited by a physiotherapist nor an occupational therapist during two months at home. In this period, the majority of the amputees (68%) had phantom pain or residual limb pain (21%). Two months after amputation the pain intensity was significantly lower (VAS = 4.07 +/- 2.19; 2.34 +/- 1.41; p < 0.001), and the functional status significantly better than on discharge (FIM = 75.13 +/- 16.52; 87.87 +/- 16.48; p < 0.001). The amputees had the average level of social dysfunction (SDRS = 62.00 +/- 11.68) and conditions of habitation (SCH = 7.81 +/- 1.97). CONCLUSION: A total 38 elderly amputees with unilateral lower limb amputations achieved significant functional improvement and reduction of pain, in spite of their social dysfunction, the absence of socio-medical support and inadequacy of the conditions of habitation.

Effect of transcutaneous electrical nerve stimulation for the management of postoperative surgical pain after lower extremity amputation: a pilot study / Efeito da estimulação elétrica nervosa transcutânea (TENS) no tratamento de dor pós-cirúrgica após amputação de membro inferior: estudo piloto

A estimulação elétrica nervosa transcutânea (TENS) é uma modalidade não-médica e não-invasiva. Há muita controvérsia e atitudes contrárias em relação ao lugar que a TENS ocupa no tratamento da dor após amputação de membro inferior. Objetivo: Avaliar o papel da TENS no tratamento de dor cirúrgica pós-operatória após amputação de membro inferior. Material e métodos: Teste controlado randomizado, conduzido com 46 indivíduos submetidos à amputação de membro inferior, que foram aleatoriamente divididos em grupo controle e grupo tratado. O grupo controle recebeu cuidados-padrão no pós-operatório; o grupo tratado recebeu cuidados-padrão e aplicação de TENS. Quarenta indivíduos completaram efetivamente o estudo de acordo com o protocolo de estudo. A maior parte das amputações consistiu de amputação transtibial devido a complicações da diabete. Foram utilizados cinco dispositivos portáteis Ultima TENS XL-A1 com eletrodos auto-adesivos. Esta é a aplicação convencional da TENS, caracterizada pela aplicação de impulsos elétricos com a duração de 200 microssegundos, freqüência de 110 Hz e amplitude de 44 V. O tratamento foi administrado durante 10 dias, 2 horas por dia. A avaliação da eficácia da TENS foi feita utilizando-se a escala visual analógica (EVA) horizontal (0-100 mm). O teste t de Student foi usado na análise estatística. Resultados: A intensidade da dor estava significantemente diminuída em ambos os grupos no 10º dia em comparação ao 1º dia de pós-operatório. Não houve diferenças significantes entre o grupo controle (EVA = 4,18±1,48) e o grupo tratado (EVA= 3,59±1,44), de acordo com a intensidade média diária da dor (t = 1,25; df=38). A intensidade da dor no 10º dia de pós-operatório foi significantemente menor no grupo tratado (EVA = 1,65± 0,80 ) versus o grupo controle (EVA = 3,2± 1,15; t = 5; df = 38; p< 0,01 ). Conclusão: A TENS convencional (dose: 200 microssegundos, 110 Hz, 44 V), administrada 2 horas por dia, durante 10 dias, significantemente reduziu a dor cirúrgica pós-operatória em 20 indivíduos com amputação de membro inferior.

Transcutaneous electrical nerve stimulation (TENS) is a noninvasive, nonmedical modality. There are a lot of dilemmas and opposing attitudes regarding the use of TENS in pain management after lower limb amputations. Objective: To establish the role of TENS for the management of postoperative surgical pain after lower limb amputations. Material and methods: Randomized controlled trial, which included forty-six subjects who had undergone lower limb amputations, randomly divided into control and treatment group. The control group received standard postoperative care, whereas the treatment group received standard postoperative care plus TENS. Forty subjects successfully completed the study according to the study protocol. The majority of the individuals had undergone transtibial amputation due to complication of diabetes. Five Ultima TENS XL-A1 portable devices with four self-adhesive electrodes were used. This was the conventional TENS mode, characterized by the delivery of electrical impulses with a duration of 200 microseconds, frequency of 110 Hz, and amplitude of 44V. Treatment was carried out for 2 hours a day, during 10 days. The evaluation of TENS efficacy was performed using the horizontal VAS (0-100 mm). Student T test was used in the statistical analysis. Results: Pain intensity was significantly diminished in both groups at the tenth in comparison with the first postoperative day. There was no significant difference between the control (VAS = 4.18±1.48) and the treatment group (VAS= 3.59±1.44) according to the daily mean pain intensity (t = 1.25; df =38). Pain intensity on the tenth postoperative day was significantly lower in the treatment (VAS = 1.65± 0.80) when compared with the control group (VAS = 3.2± 1.15; t = 5; df = 38; p< 0.01). Conclusion: Conventional TENS (dose: 200 microseconds, 110 Hz, 44V), administered two hours a day during ten days, significantly reduced postoperative surgical pain in twenty subjects who had undergone lower limb amputations.