[Relevance of personal contextual factors of the ICF for use in practical social medicine and rehabilitation]. / Bedeutung der personbezogenen Faktoren der ICF für die Nutzung in der praktischen Sozialmedizin und Rehabilitation.

Personal contextual factors play an essential part in the model of the International Classification of Functioning, Disability and Health (ICF). The WHO has not yet classified personal factors for global use although they impact on the functioning of persons positively or negatively. In 2010, the ICF working group of the German Society of Social Medicine and Prevention (DGSMP) presented a proposal for the classification of personal factors into 72 categories previously arranged in 6 chapters. Now a positioning paper has been added in order to stimulate a discussion about the fourth component of the ICF, to contribute towards a broader and common understanding about the nature of personal factors and to incite a dialogue among all those involved in health care as well as those people with or with-out health problems in order to gain a comprehensive perspective about a person's condition.

Bone metabolism in patients with primary hyperparathyroidism before and after surgery.

Primary hyperparathyroidism (PHPT) is accompanied with a reduced bone mineral density (BMD) and an increased risk of fracture. Surgery is the only option for cure. It is hypothesized that in patients with PHPT bone metabolism normalizes after parathyroidectomy (PTX) and that BMD gradually increases. Fifty-two patients with PHPT who underwent surgery were prospectively followed for 1 year. Biochemical analyses were performed at baseline and 1, 4, 7 days; 6 weeks; and 3, 6, and 12 months, and BMD before and one year after surgery. Parathyroid hormone (PTH), calcium, and the bone resorption marker dropped immediately, but transiently after PTX, bone formation decreased more slowly. Osteoprotegerin (OPG) as well as cathepsin K did not show significant changes. BMD of the lumbar spine, but not of the femoral neck, increased significantly within one year after surgery. Moderate correlations existed between the changes of total calcium, ionized calcium, as well as bone-specific alkaline phosphatase and changes of the lumbar BMD. Patients who needed postoperative supplementation with calcium and vitamin D had significantly higher PTH levels. Some gender-specific differences in patients with PHPT were observed. In patients with PHPT, males appear to be more severely affected than females. Within the first year after PTX, bone metabolism normalized, and BMD of the lumbar spine increased. Patients who needed a supplementation with calcium and vitamin D after PTX preoperatively had higher serum levels of PTH.

Serum levels of tumour necrosis factor-alpha and interleukin-6 and their correlation with body mass index, weight loss, appetite and survival rate--preliminary data of Viennese outpatients with metastatic cancer during palliative chemotherapy.

The serum cytokine levels (in particular interleukine-6 (IL-6) and tumour necrosis factor-alpha (TNF-alpha)) of 61 advanced stage cancer patients receiving palliative chemotherapy as outpatients were determined with quantikine immunoassays. The values were correlated with body mass index (BMI), weight loss and appetite. Furthermore cytokine levels of patients who have died within one year were compared with those of patients who have survived more than a year. Serum levels of IL-6 (median: 1.93 pg/ml, range: 0.32-42.87) and of TNF-alpha (median: 2.55 pg/ml, range: 1.03-34.06) did not correlate with BMI, weight loss and appetite. Serum IL-6 levels of patients with survival time less than one year were significantly higher than the levels of patients who survived more than one year, no significant differences in TNF-alpha serum levels were evident. The data of this observation are consistent with current literature. Due to changes in serum levels of proinflammatory cytokines in response to chemotherapy and additional therapy, it is unlikely that IL-6 and TNF-alpha can be used as independent indicators for weight loss and appetite. Nevertheless, high serum levels of IL-6 correlate with short-time mortality.

The effects of low-dosed and high-dosed low-frequency electromagnetic fields on microcirculation and skin temperature in healthy subjects.

The purpose of this randomized double-blind cross-over study was to investigate whether a low-dosed pulsed low-frequency magnetic field or a high-dosed pulsed low-frequency magnetic field improves the cutaneous microcirculation and alters the temperature of the foot. Twelve healthy subjects (five women, seven men) aged on average 25.8 years participated in the trial. Based on a randomization list, one of the following three interventions was applied for 30 min through a cushion placed below the non-dominant foot: either a pulsed low-dosed magnetic field (100 uT, basic frequency 30 Hz with a frequency modulation) or a pulsed high-dosed magnetic field (8.4 mT, 10 Hz), or sham treatment. The individual treatment sessions were applied in intervals of one week, at the same time of the day. Cutaneous microcirculation (laser Doppler flowmetry) and temperature (infra-red thermovision) were measured in the dorsum of the foot and the great toe every 5 min during the intervention, and 5 and 10 min post-intervention. With both pulsed low-dosed magnetic field and pulsed high-dosed magnetic field, just as with the sham treatment, a minor drop in temperature and decrease in microcirculation took place. A two-way repeated-measures analysis of variance revealed no significant difference between the interventions for any parameter. It was concluded that a local application of a pulsed low-frequency magnetic field to the foot did not enhance temperature or cutaneous microcirculation in healthy subjects.

Bone metabolism in patients more than five years after bone marrow transplantation.

We investigated the bone metabolism of 22 patients (median age 38 years) over 6 years after allogeneic bone marrow transplantation (BMT). Biplanar roentgenograms of the thoracic and lumbar spine were used to diagnose vertebral deformities caused by fractures. The actual bone mineral density (BMD) of the lumbar spine and the femoral neck were measured. Laboratory tests included calcium, phosphate, parathyroid hormone, a marker of bone resorption (beta-crosslaps, CTX), markers of bone formation (osteocalcin, bone-specific alkaline phosphatase), osteoprotegerin (OPG)--antagonist of the osteoclast differentiation factor RANKL, and sex hormone status. One patient had a vertebral fracture. Seven patients (28%) had osteopenia in the lumbar spine while 12 patients (48%) had osteopenia in the femoral neck. Bone resorption was increased in nine patients (43%) and bone formation was increased in four patients (20%). BMT recipients had significantly increased serum levels of OPG (P=0.029). Three women (75%) and four men (25%) were hypogonadal. The data showed that BMD is reduced and bone metabolism is still disturbed more than 6 years after BMT. The RANKL/osteoprotegerin system appears to play an important role in the pathophysiology of late post transplantation osteoporosis.

Implementation of the Vienna Hydrotherapy Group for Laryngectomees--a pilot study.

GOALS: Laryngectomy involves several problems for the individual, such as the need to cope with a stoma, adjustment to tracheostomal breathing, and the formation of a voice. Contact with water, resulting in aspiration, may prove fatal for laryngectomized patients in the absence of appropriate aids. The aim of this pilot study was to conduct a hydrotherapy group for laryngectomized patients and to evaluate its feasibility and outcome in relation to the goals of therapy. PATIENTS AND METHODS: Six male patients who had undergone laryngectomy were included in a pilot study. The patients underwent a structured hydrotherapy rehabilitation program (three times a week for 8 weeks), using a special underwater therapy device. The patients' posture was controlled by posturography and their endurance capacity by standard ergometry and the 6-min walk. The parameters of fatigue, expectoration, mobility, elasticity/flexibility, postural control/coordination, and general well being were registered on a visual analog scale (VAS). Quality of life was assessed by having the patients fill out the German version of the SF-36 Health Survey. MAIN RESULTS: Posturograpy findings showed an improvement of two subtests ( p<0.028). Exercise testing showed an improved endurance capacity ( p<0.028). The patients were able to walk a greater distance in the 6-min walking test ( p<0.028). The VAS also showed an improvement of endurance capacity ( p<0.028), fatigue ( p<0.028), expectoration ( p<0.043), mobility of the neck and shoulder ( p<0.027), flexibility ( p<0.027), postural control and coordination ( p<0.028), and general well being ( p<0.028). On the SF-36 Health Survey, the patients were improved in the items "Physical functioning" ( p<0.027), "Vitality" ( p<0.027) "Role-physical" ( p<0.026), and "Social functioning" ( p<0.043). CONCLUSIONS: A hydrotherapy group for laryngectomized patients proved to be safe, feasible, and effective in this pilot study.

Rehabilitation of ligamentous ankle injuries: a review of recent studies.

There are many treatment modalities for ankle rehabilitation. These are reviewed, and the most effective training programme for rapid restoration of ankle movement, strength, endurance, and proprioception is selected.

Aerobic exercise for a patient suffering from metastatic bone disease.

A 48-year-old female patient suffering from advanced breast cancer with metastatic bone disease participated in an aerobic exercise program consisting of ergometer cycling three times a week for 1 year. Feasibility, safety and beneficial effects of the program were proven for the patient in this case study. VO(2)max (20.2% after 16 weeks, 52.7% after 12 months) and peak work capacity (15.5% after 16 weeks, 35.7% after 12 months) had increased. The patient experienced a marked improvement in physical performance and in quality of life. Aerobic exercise, initiated and executed with appropriate care, may serve as a useful additional means of palliative treatment in some cancer patients with bone metastases.

Effectiveness of exercise therapy in patients with myofascial pain dysfunction syndrome.

UNLABELLED: Twenty consecutive patients suffering from myofascial pain dysfunction (MPD) were assigned to a waiting-list, serving as a no-treatment control period. Inclusion criteria were: (i) pain in the temporomandibular region for at least 3 months, (ii) no evidence of internal derangement or osteoarthritis and (iii) symptoms of postural dysfunction. Treatment consisted of active and passive jaw movement exercises, correction of body posture and relaxation techniques. The following main outcome measures were evaluated: (i) pain at rest, (ii) pain at stress, (iii) impairment, (iv) mouth opening at base-line, before and after treatment and at 6-month follow-up. All patients completed the study and no adverse effects occurred. During control period no significant changes occurred. After treatment six patients had no pain at all (chi-square: P < 0.01) and seven patients experienced no impairment (chi-square: P < 0.005). Pain at stress, impairment and incisal edge clearance improved significantly (Wilcoxon test P < 0.001). This result did not change until follow up, except pain at stress, which further improved significantly (Wilcoxon test P < 0.03). At follow up 16 patients experienced no pain at all, 13 patients were not impaired and only three patients had a restricted mouth opening, in contrast to 12 before treatment (chi-square test P < 0.001). CONCLUSION: Exercise therapy seems to be useful in the treatment of MPD Syndrome.

Reliability of pelvic floor muscle strength measurement in elderly incontinent women.

Pelvic floor muscles (PFM) play an important role in maintaining urinary continence with increasing age. Therefore, their contractile properties need to be evaluated. The aim of the study was to examine the reliability and correlation of simple techniques to measure PFM strength in elderly women with urinary incontinence. An interview was used to evaluate the ability to stop the urinary stream during micturition and to calculate the incontinence index. A pad test was applied to objectively evaluate the severity of the disease. Functional testing included a digital examination to measure the force and duration of one contraction, a perineometer measurement (Peritron) to assess maximal contraction force and contraction force of 5 s, and a cone-retention test (Femcon) while walking for 1 min and during Valsalva's manoeuvre. This procedure was performed on three separate occasions within one week. The 37 participating women with a mean age of 62+/-8 (mean+/-SD) years had a severity index of 4.4+/-2.6 and a urine loss of 9.5+/-13.6 mg during the pad test. Sixteen women were able to completely stop the urinary stream during micturition. The digital examination showed no intratester variability. The perineometer measurement showed that the absolute difference in maximal contraction force and mean contraction force within 5 s was less than 5.3 mm Hg and 4.5 mm Hg, respectively, with a probability of 0.95. While walking and during Valsalva's manoeuvre, 19 and 20 women, respectively, held the same cone in place on all three occasions. The maximal contraction force and mean force during the 5-s contraction correlated well with the ability to stop the urinary stream and the digital examination but only weakly with the cone-retention tests. The reliability of PFM strength measurement is highest in the digital examination, followed by perineometer measurements, and then by vaginal cone tests. As PFM function is easy to assess, it should be routinely done in the assessment of urinary incontinence in elderly women.

Health related quality of life in patients with long-standing insulin dependent (type 1) diabetes mellitus: benefits of regular physical training.

BACKGROUND AND AIMS: Regular exercise is recommended to diabetic patients in addition to dietary restrictions and drug therapy. We have studied whether health related quality of life (HRQOL) can be improved by a regular physical training program. METHODS: 23 otherwise healthy patients with history of type 1 diabetes for 20 +/- 10 years were included. 15 patients (age: 41 +/- 2 years) participated in an aerobic physical training program over 4 months and 8 patients (33 +/- 11 years) served as a control group. HRQOL was assessed by a validated questionnaire (MOS SF-36). Tests were carried out at baseline and after 4 months. RESULTS: Physical training increased peak oxygen uptake (VO2max) by 27 +/- 13% after 4 months (p = 0.04) in the training group. There was no significant change in hand or leg isometric muscle strength. All HRQOL scales improved in the training group with significantly higher (p < 0.04) Social Functioning and Vitality scores, respectively. Moreover, insulin requirements decreased during physical training program (p < 0.05). CONCLUSIONS: Our data indicate that physical exercise training in patients with type I diabetes mellitus improves metabolic control and various aspects of HRQOL. Besides enhanced cardiorespiratory capacity, this is an important subjective benefit in patients with longstanding insulin dependent (type 1) diabetes mellitus.

Neuromuscular electric stimulation in heart transplantation candidates with cardiac pacemakers.

Twenty percent of heart transplantation candidates have cardiac pacemakers. Application of neuromuscular electric stimulation (NMES) in patients with pacemakers is controversial because of potential electromagnetic field interference and subsequent failure of the pacemaker. We present a safety protocol as a procedure before applying NMES in pacemaker patients. In 4 patients with chronic heart failure, NMES was applied under supervised conditions for 20 minutes to evaluate the individual risk. No changes in the clinical state and no complications secondary to electromagnetic field interference were observed. A check of pacemaker function after this 20-minute stimulation revealed no changes in the pacemaker parameters. After a thorough safety protocol, NMES of knee extensor muscles in patients with pacemakers appears to be safe.

Short segment stimulation of the anterior transposed ulnar nerve at the elbow.

OBJECTIVE: To determine whether short segment stimulation after anterior subcutaneous transposition of the ulnar nerve reaches normal values and correlates with postoperative clinical findings. DESIGN: Comparative cross-sectional study. SETTING: Outpatient clinic of a university department of physical medicine and rehabilitation. PATIENTS: Nineteen patients (15 men, 4 women) with 21 surgically treated ulnar neuropathies at the elbow; and 19 healthy controls (11 men, 8 women) with 24 measured nerves. INTERVENTIONS: Assessed motor function of ulnar innervated muscles and staged into 4 categories; used questionnaire to assess clinical course of the nerve lesion and graded into 5 categories; took electrophysiologic recordings to measure motor conduction velocity and compound muscle action potentials; and studied short segment stimulation across elbow and lower arm. MAIN OUTCOME MEASURES: Mean +/- standard deviation of ulnar short segment conduction time across the elbow, amplitude and motor conduction velocity; grading of ulnar nerve lesions; grading of the course of disease after surgery; and logistic regression and correlation (Spearman's correlation coefficient) for electrophysiologic and clinical parameters. RESULTS: Sixteen nerves showed focal conduction slowing in patients. No significant correlation between the course of disease and electrophysiologic parameters was seen. For stepwise logistic regression, there was a significant effect between grade of nerve lesion and amplitude, but no significant effect between the course of disease and electrophysiologic parameters. CONCLUSION: A focal conduction slowing across the elbow after anterior subcutaneous transposition does not correlate with postoperative clinical findings.

Cross-cultural adaptation of the Minnesota Living with Heart Failure Questionnaire for German-speaking patients.

We performed a cross-cultural adaptation of the "Minnesota Living with Heart Failure Questionnaire" (LHFQ) for use in German-speaking chronic heart failure patients. The instrument was translated and back translated, pre-tested and reviewed by a committee. The German version was tested in 114 patients with chronic heart failure. Reliability was assessed by a test-retest procedure and Cronbach's coefficient alpha of internal consistency (0.94). To assess concurrent validity, we compared the LHFQ sum scores with the New York Heart Association classification rating (r = 0.53; p < 0.0001), the 6-minute walk (r = -0.39; p < 0.0001), the left ventricular ejection fraction (r = -0.24; p = 0.011) and big-endothelin (r = 0.27; p = 0.004). Construct validity on the LHFQ scores in comparison with the Medical Outcomes Study SF-36 Health Survey (MOS SF-36) was significant (-0.41 to -0.74; all p < 0.0001). The reliability and validity of the German version of the LHFQ was proved; the questionnaire can be recommended for use in future clinical trials.

Whole-body vibration exercise leads to alterations in muscle blood volume.

Occupationally used high-frequency vibration is supposed to have negative effects on blood flow and muscle strength. Conversely, low-frequency vibration used as a training tool appears to increase muscle strength, but nothing is known about its effects on peripheral circulation. The aim of this investigation was to quantify alterations in muscle blood volume after whole muscle vibration--after exercising on the training device Galileo 2000 (Novotec GmbH, Pforzheim, Germany). Twenty healthy adults performed a 9-min standing test. They stood with both feet on a platform, producing oscillating mechanical vibrations of 26 Hz. Alterations in muscle blood volume of the quadriceps and gastrocnemius muscles were assessed with power Doppler sonography and arterial blood flow of the popliteal artery with a Doppler ultrasound machine. Measurements were performed before and immediately after exercising. Power Doppler indices indicative of muscular blood circulation in the calf and thigh significantly increased after exercise. The mean blood flow velocity in the popliteal artery increased from 6.5 to 13.0 cm x s(-1) and its resistive index was significantly reduced. The results indicate that low-frequency vibration does not have the negative effects on peripheral circulation known from occupational high-frequency vibration.

A neuromuscular test battery for osteoporotic women: a pilot study.

OBJECTIVE: To examine the efficacy of a short neuromuscular test battery in elderly women suffering from osteoporosis in accordance with the World Health Organization criteria, with and without a history of fractures. Reduced bone mass and a high likelihood of falling increase the risk of osteoporotic fractures. There is a need for neuromuscular tests to identify individuals at risk for falls and fractures. DESIGN: The women were assessed twice. Forty-two women, with a mean age of 70.0 +/- 5.1 (SD) yr, completed the first assessment. The number of postmenopausal fractures and the women's history with regard to agility and falls were assessed. The women performed neuromuscular tests (one-leg stance, tandem walk, and body sway); bone mineral density of the spine and femoral neck were measured. For the follow-up assessment, 13.2 +/- 1.3 mo later, 39 women were studied. The same outcome measurements were obtained at both evaluations. RESULTS: During the observation period, five women fell once and one woman fell twice; there were only two vertebral fractures and no nonvertebral fracture. Neuromuscular performance did not change during this observation period. The median changes in bone mineral density between the two assessments were clinically not relevant. A comparison between patients suffering from established osteoporosis and osteoporotic patients without a history of postmenopausal fractures showed that both groups of patients did not differ with respect to age, neuromuscular performance, bone mineral density, and fear of falling. CONCLUSION: This neuromuscular test battery is a feasible and practical tool because it is brief and economical to perform. However, its efficacy as a predictor of fractures must be tested in additional studies with a long-term follow-up and a larger group of subjects.

Isokinetic strength testing in patients with chronic heart failure--a reliability study.

Measurement of skeletal muscle strength gains increasing importance as outcome parameter in patients with chronic heart failure. This study aimed at establishing short-term reliability of isokinetic strength measurements of knee extensor and flexor muscles in 38 patients with chronic heart failure. Strength tests were performed on the Cybex 6000 dynamometer. Trunk fixation was restricted to pelvic fixation. Two bouts of strength testing were performed on day 1 and one on day 5. Each isokinetic bout consisted of 3 reciprocal knee extension and flexion movements with an angular speed of 60 degrees per second. Isometric strength was measured at 30 degree knee angulation. Intraclass correlations ranged between 0.96 and 0.99 for isokinetic and isometric peak torque of knee extensor muscles and 0.82-0.96 for flexor muscles. Analysis of repeated measurements showed significant differences among the values of flexor peak torque in the isokinetic mode and between all measurements in the isometric mode (p < 0.05). Pearson's correlation coefficients for isokinetic and isometric extensor peak torques ranged between 0.95 and 0.99, for flexor peak torques between 0.81 and 0.85 (all p < 0.0001). Measurement of isokinetic knee extensor and flexor peak torque is a reliable method to assess muscle strength in patients with chronic heart failure even with altered trunk fixation.

Improvement of thigh muscles by neuromuscular electrical stimulation in patients with refractory heart failure: a single-blind, randomized, controlled trial.

OBJECTIVE: To determine the impact of an 8-wk neuromuscular stimulation program of thigh muscles on strength and cross-sectional area in patients with refractory heart failure listed for transplantation. DESIGN: Forty-two patients with a stable disease course were assigned randomly to a stimulation group (SG) or a control group (CG). The stimulation protocol consisted of biphasic symmetric impulses with a frequency of 50 Hz and an on/off regime of 2/6 sec. RESULTS: Primary outcome measures were isometric and isokinetic thigh muscle strength and muscle cross-sectional area. Our results showed an increase of muscle strength by mean 22.7 for knee extensor and by 35.4 for knee flexor muscles. The CG remained unchanged or decreased by -8.4 in extensor strength. Cross-sectional area increased in the SG by 15.5 and in the CG by 1.7. CONCLUSIONS: Activities of daily living as well as quality of life increased in the SG but not in the CG. Subscales of the SF-36 increased significantly in the SG, especially concerning physical functioning by +7.5 (1.3-30.0), emotional role by +33.3 (0-66.6), and social functioning by +18.8 (0-46.9), all P < 0.05. Neither a change nor a decrease was observed in the CG. Neuromuscular electrical stimulation of thigh muscles in patients with refractory heart failure is effective in increasing muscle strength and bulk and positively affects the perception of quality of life and activities of daily living.