[Spanish validation of the Autonomic Standards Assessment Form in spinal cord injuries]. / Validación española del cuestionario Autonomic Standards Assessment Form en la lesión medular.

INTRODUCTION AND OBJECTIVES: Autonomic nervous system (ANS) dysfunction in patients with spinal cord injury (SCI) severely impacts morbidity and mortality. However, research initiatives aiming to gain insight into the direct impact of ANS dysfunction on health outcomes in persons with SCI are still lacking. Thus, this study had 2main objectives: 1) to translate into Spanish the revised edition of the International Standards on documentation of remaining Autonomic Function after SCI (ISAFSCI), and 2) to describe the impact of ANS dysfunction in a sample of SCI patients. MATERIAL AND METHODS: Cross-sectional observational pilot study in 51 traumatic SCI patients (> 1 year after injury). Demographic, medical and ISAFSCI data were studied. RESULTS: The Spanish version of the ISAFSCI showed that the most altered systems in the sample were sweating control (above-lesion hyperhidrosis in 33.3%; below-lesion hyperhidrosis in 17.6%; below-lesion hypohidrosis in 21.6%) and temperature control (hyperthermia in 76.5%). In addition, 74.5% of the sample had complete loss of control of the lower urinary tract, and 82.4% had no control of the bowel. Finally, genital arousal was reflex in 47.1% and orgasm and ejaculation were reduced or altered in most of the patients (92.2% and 84.3%, respectively). CONCLUSION: The Spanish version of the ISAFSCI is a useful and practical tool, and can be employed in clinical practice to assess ANS function in patients with SCI. Understanding the role of ANS in persons with SCI is crucial to improve their health status and reduce secondary complications post-SCI, and consequently help to improve the clinical management in these individuals.

Comorbidity and physical activity in people with paraplegia: a descriptive cross-sectional study.

STUDY DESIGN: Descriptive cross-sectional study. SETTING: The study was conducted in the Spinal Cord Injury Unit of the University Vall d'Hebron Hospital and in the Physical Education and Sports Department of the University of Valencia. OBJECTIVES: The aim of this study was to quantify the presence of comorbidities in spinal cord injury (SCI) subjects who did or did not perform regular physical activity (PA) and to identify the relationship between PA and the level of comorbidity. METHODS: The sample consisted of patients with complete motor SCI (T2-T12), who were fitted with an accelerometer attached to the non-dominant wrist for a period of 1 week. The clinical and blood analytic variables were selected by an expert panel. RESULTS: In the exploratory analysis, we have found differences in the total number of pathologies between active and inactive patients, with fewer total pathologies in the active patient group. An association was found between the PA level and diabetes mellitus (; P=0.047; φ=0.25). We also observed an association between the cardioprotector level of high-density lipoprotein (HDL)-cholesterol and PA level (; P=0.057; Φ0.24). CONCLUSIONS: Our results suggest that patients considered active showed lower total comorbidity than inactive patients and higher protection levels against developing cardiovascular comorbidity.

Physical and Psychosocial Functions of Adults with Lower Limb Congenital Deficiencies and Amputations in Childhood.

Objectives. (1) To describe the epidemiological and medical features of a sample with LLA and LLD in childhood and (2) to explore their relationship with subsequent physical and psychosocial functions in adulthood. Methods. Cross-sectional survey. Demographics, medical data, Locomotor Capabilities Index (LCI), and Discomfort-Engagement in Everyday Activities Involving Revealing the Body Scale (D-EEARB) were collected from thirty-two adults who suffered from LLA in childhood or LLD. Results. Most of the sample (53.1% males) was working (84.4%), living independently (75%), and single (75%). Mean age was 33.16 (SD = 7.64, range 18-50). Leading causes for LLA were traumatic (40.6%) and oncologic (25%). LLD was present in 6 cases (18.8%). LCI scores revealed a high performance among males (t 17,464 = 2.976, p = .008). D-EEARB scores showed that 56.25% stated feeling "quite" or "totally comfortable" in situations which involved revealing their body, but 43.75% stated the contrary ("uncomfortable" or "very uncomfortable"). LLD and traumatic LLA show higher scores in D-EEARB than vascular and oncological LLA (χ (2) = 7.744, df = 3, p = .05). Conclusions. Adults suffering from LLDs and LLAs during childhood seem to perform well once they are adults. However, 43.75% of patients express considerable discomfort in situations that involve revealing the body.

Descenso de la estancia media en la Unidad de Lesionados Medulares. Implicaciones éticas sobre la asistencia / Decrease in the mean stay in the spinal cord injury unit. Ethical implications on the care

La estancia media (EM) es un factor importante para determinar la actividad asistencial y un indicador para el pago en determinados sistemas de salud. Se ha demostrado que ha descendido drásticamente, durante los últimos años, en los pacientes ingresados en los Servicios de Rehabilitación. Hemos analizado la evolución de la EM y el grado de complejidad del proceso asistencial, en el período comprendido entre los años 1997 y 2009, determinando la tendencia que sigue y como se ha visto influida por los cambios en el modelo asistencial, para conocer las modificaciones que se han producido en la gestión del proceso lesión medular y las implicaciones éticas que puede tener sobre el modelo asistencial. El número de pacientes en el período 1997-2009, ha sido de 907 con una media anual de 69,7 pacientes/año. La edad media es de 44,8 años (DE: 18,2), con un rango que varía entre 15 y 84 años y una mediana de 41 años. La edad media se ha incrementado de forma significativa (p<0,001) cuando se comparan los períodos 1997-2002 y 2003-2009. La EM en la unidad de cuidados intensivos, en los pacientes que lo precisaron, antes del ingreso en la Unidad de Lesionados Medulares (ULM), ha sido de 12,3 días (DE: 18,2) para las tetraplejías y de 15 días (DE: 19,6) para los paraplejías. El promedio de EM en la ULM ha sido de 66,4 días, con un rango que varía de 85,2 en 1997 a 55,4 en 2003. Se observa una reducción significativa de la EM, ostensible a partir de 2001, con descensos progresivos hasta 2003, estabilizándose a partir de ese año, existiendo diferencias significativas (p<0,0001) entre el período 1997-2002 y el 2003-2009. El grado de complejidad del proceso leucemia mieloide agudase ha incrementado de forma notable a partir de 2004, teniendo una media los grupos relacionados por el diagnóstico (GRD)en el período estudiado, de 5,37, con un rango que varía entre 3,79 en 1997 y 9,4 en 2009. Más de un 40% de los pacientes tienen GRD elevados, superiores a 5 puntos y un 10% tienen valores excesivos, superiores a 20 puntos. Se ha objetivado correlación entre EM más altas y mayor número de lesiones asociadas y mayor gravedad de la lesión, con una correlación significativa (p<0,01; r=78) entre EM más alta y GRD más alto. En conclusión, los cambios detectados a través de este estudio en cuanto a la incidencia EM y morbilidad añadida a la lesión medular aguda, evaluada a través de los GRD, indica que es necesario trabajar con el gobierno y los compradores de la salud en las CC.AA., para demostrar que la reducción de la EM, tienen un límite situado en el equilibrio entre la atención eficiente y la tolerable éticamente y que no siempre representan una gestión más rentable, por lo que será preciso tener en cuenta el grado de discapacidad de los pacientes y el análisis continuo de los procesos (AU)

Mean stay (MS) is an important factor to determine the care activity and is an indicator for payment in some health care systems. It has been shown that it has dramatically decreased in patients admitted in rehabilitation services during the last years. We have analyzed the evolution of EM and the degree of complexity of the health care process from 1997 to 2009. We have determined the tendency it has been following and how it has been influenced by the changes in the care model in order to discover the modifications that have been made in the management of the spinal cord injury process and the ethical implications it may have on the care model. The number of patients in the period 1997-2009 was 907 with an annual average of 69.7 patients/year. Average age was 44.8 years (SD: 18.2), with a range that varied from 15 to 84 years and a median of 41 years. Mean age increased significantly (P<0.001) when the periods 1997-2002 and 2003-2009 are compared. Mean stay (MS) in the ICU was 12.3 days (SD: 18.2) for tetraplegia and 15 days (SD: 19.6) for paraplegia. Mean stay in the spinal cord injured unit (SCI) was 66.4 days, with a range varying from 85.2 in 1997 to 55.4 in 2003. We observed a significant reduction of MS, ostensibly from 2001, with a steady decline until 2003, it stabilizing after this year, and with significant differences (P<0.0001) between the period 1997-2002 and 2003-2009. The complexity degree of SCI has increased significantly since 2004, with an average 5.37 diagnostic related groups (DRG), during the period study, and a range that varied from 3.79 in 1997 to 9.4 in 2009. More than 40 percent of the patients have elevated GRDs, greater than 5 points, and 10 per cent of patients have excessive values, which are considered to be more than 20 points. Correlations have been observed between higher MS and increased number of associated lesions, and greater severity of the injury, with a significant correlation (P<0.01; r=78) between higher MS and higher DRG. In conclusion, the changes detected by this study in regards to incidence, MS and morbidity added to the acute spinal cord injury, evaluated through the GRD, indicate the need to work with the Government and health care purchasers in the Autonomous Communities to demonstrate that the reduction of MS has a limit. This limit is found within the balance between efficient and ethically tolerable care, which does not always mean a more profitable process. Thus, it will be necessary to take into account the degree of disability of patients and the continuous analysis of processes (AU)

Conflictos éticos en el aprendizaje de los médicos internos residentes de Medicina Física y Rehabilitación / Ethical conflicts in training of the medical residents of physical medicine and rehabilitation

Objetivo. Intentar identificar el lugar que ocupa el concepto ético en la actuación diaria de los médicos internos residentes (MIR) de Medicina Física y Rehabilitación. Material y método. Se realizó un estudio prospectivo en el que participaron 13 MIR de Medicina Física y Rehabilitación con el objetivo de identificar los conflictos éticos que pueden producirse durante el aprendizaje de la especialidad. Realizamos un documento para el análisis de las habilidades éticas que consistía en 10 casos clínicos de situaciones habituales en rehabilitación. Todas las preguntas tenían cinco respuestas posibles en las que se incluían los indicadores para la evaluación de la ética médica. Las respuestas podían ser: a) respeto o actitud basada en los principios de autonomía, beneficencia, ausencia de maleficencia y justicia; b) evasión en la que se subroga el compromiso de actuar a una autoridad o a otros colegas, y c) falta de respeto, que es la ausencia de respeto a la autonomía del paciente, las actitudes no beneficientes, la maleficencia o la injusticia. Resultados. Sobre un rango máximo total de todos los participantes de 1.300 puntos se obtuvieron 1.008,5 puntos, lo que significa el 77,6% y está situado en el mejor cuartil. Resultados. La media del grupo fue de 25,2 puntos (desviación estándar de 2,8) con un rango situado entre 22,5–27,1 puntos. Las preguntas con resultados más inadecuados fueron la 8 y la 9, referidas a la falta de colaboración del paciente y a las actitudes inadecuadas de otros profesionales del equipo multidisciplinario de rehabilitación. Conclusión. El estudio indica la necesidad de institucionalizar programas de formación específicos para los MIR en el apartado ético(AU)

Objective. To attempt to identify the place occupied by the ethical concept in the daily performance of resident physicians (RP) of Physical Medicine and Rehabilitation (PMR). Material and methods. A prospective study involving 13 RP of PMR was performed in order to identify the ethical conflicts that may occur during the specialty training. We elaborated a document for the analysis of ethical skills, which consisted of 10 clinical cases of common situations in Rehabilitation. All the questions had 5 possible answers that included indicators for the evaluation of medical ethics. The answers could be: a) Respect or attitude based on the principles of autonomy, beneficence, non-malfeasance and justice, b) avoidance in which commitment to act is subrogated to an authority or other colleagues, c) lack of respect, which is the absence of respect of the patient's autonomy, non-beneficence, malfeasance or injustice attitudes. Results. On a total maximum range for all the participants of 1300 points, 1008.5 points were obtained. This accounts for 77.6%, which would be located in the best quartile. The group average was 25.2 points (SD 2.8), with a range located between 22.5 and 27.1 points. The questions having the most inadequate results were numbers 8 and 9, concerning lack of patient cooperation and inappropriate attitudes of other professionals in the multidisciplinary rehabilitation team. Conclusion. The study indicates the need to institutionalize specific training programs for the Resident Physician within the ethics section(AU)

Incidencia del dolor neuropático en el lesionado medular / Neuropathic pain in chronic SCI patients

Objetivo. Conocer la incidencia de dolor neuropático (DN), mediante el cuestionario DN4, en la población de lesionados medulares (LM) de nuestro medio, dado que existe poca información a este respecto. Material y método. Se efectúa estudio prospectivo, aleatorizado, de la muestra de pacientes con lesión medular crónica que ya finalizaron tratamiento rehabilitador, los que acudieron a consultas externas de Unidad de Lesionados Medulares, durante 01/06/2007–31/12/2007. Para valorar la incidencia del DN hemos utilizado el cuestionario DN4. Se realizó un estudio bivariable con SPSS(R) 15. Resultados. Noventa y cinco pacientes (65 varones y 30 mujeres), con una edad media 42,91 (DE 16,57). Cuarenta y seis eran lesiones completas sensitivas y 49 incompletas sensitivas. Treinta y dos cervicales, 22 dorsales altos, 24 dorsales bajos y 17 lumbares. El tiempo de evolución medio de la lesión era 98,33 meses (DE 98,80). La puntuación media DN4 fue 4,44 (DE 2,48). La incidencia de DN en la muestra es 66,3%. No existieron diferencias significativas entre DN y las variables sensibilidad (completo sensitivo o incompleto sensitivo), nivel de localización de la lesión, tiempo de evolución de la lesión y sexo. Únicamente existió asociación estadísticamente significativa entre la edad y el DN (36 vs 46,42). Existía correlación positiva entre edad y puntuación del DN4 (p<0,05). Conclusiones. El 66,3% de los LM crónicos presentan DN, siendo este más frecuente en las LM incompletas, está relacionado con la edad, pero no con el sexo ni el tiempo de evolución de la LM (AU)

Objective. To understand the incidence of neuropathic pain (DN), through the DN4 questionnaire, in the chronic SCI patients, as there is little information in this regard. Design. A prospective, randomized study. Participants. It was performed with 245 patients with SCI in chronic phase to knowing the incidence of neuropathic pain (DN). Interventions. DN4 test evaluated neurophatic pain. Methods. We used to analyze the results the statistic program SPSS(R) 15. Results. The sample was 95 patients, 67% males and 33% women, with an average age of 42.91 years (SD 16.6). The time of evolution of SCI was 98.3 months (range 15–360). The proportion of patients with ASIA A was 50%. The prevalence of DN was 66.3%. The most common form of presentation of DN was numbness to 55% and electric shocks for 40%. There are correlation between DN with age p=0,005, but not with sex or the time of evolution of SCI. Conclusions. 66,3% of patients with chronic LM presented DN. It is more frequent in the incomplete SCI, and it is correlated with age, but not with sex or the time of evolution of the SCI (AU)

Distribución de los pacientes con lesiones medulares agudas por grupos relacionados diagnósticos / Distribution of acute spinal cord injuries by diagnoses related groups

Introducción. La atención de la lesión medular (LM) se ha visto modificada desde la introducción de los grupos relacionados diagnósticos (GRD). Material y métodos. Estudio retrospectivo de los pacientes con LM aguda dados de alta por la Unidad de Lesionados Medulares del Hospital Vall d’Hebron en el período comprendido entre el 1 de enero de 1997 y el 31 de diciembre de 2006. Material y métodos. El objetivo es conocer con qué GRD se clasifican los pacientes con LM aguda, el peso relativo de los GRD y obtener unos indicadores que nos informen sobre el tipo de pacientes con LM aguda en nuestro medio a través de los GRD. Resultados. El número de pacientes con LM aguda dados de alta por la Unidad de Lesionados Medulares del Hospital Vall d’Hebron en los últimos 10 años ha sido de 698. La edad media de la muestra fue de 40,27 (DE: 18,85); la mediana fue de 36, con un rango de 73 años. La estancia media fue de 70,34 días (DE: 43,49); la mediana fue de 65 con un rango de 182 días. El peso medio del GRD fue de 4,658 (DE: 4,99) con un rango que variaba entre 0,51–20,04. El número de pacientes considerados outliers, según grupo GRD específico, fue de 302, con una media de 30,3 pacientes outliers anualmente. Resultados. Los pacientes con LM aguda se clasifican mayoritariamente con un GRD quirúrgico, siendo el más frecuente el de las intervenciones espinales. Pero el que mayor coste genera es el GRD de traqueotomía (GRD 483-541-542) con un peso 3,7 veces superior al peso medio de nuestra muestra. Conclusiones. Se suelen clasificar con GRD quirúrgicos, pero consideramos que esta clasificación no tiene en cuenta la funcionalidad que obtienen (AU)

Introduction. The care of spinal cord injury (LM) has been changed since the introduction of GRDs. Material and methods. Retrospective study of acute spinal cord injured patients discharged by the spinal injury unit at the Hospital Vall d’Hebron (ULM_HVH) in the period from January 1 1997 and December 31, 2006. Material and methods. The aim of this study was to know that GRD classify patients with acute LM, as well as the relative weight of GRDs and get some indicators that inform us about the type of patients with acute LM in our environment through the GRDS. Results. The number of patients with acute LM discharged by the ULM-HVH in the last 10 years was 698. The average age of the sample was 40.27 (of 18.85), median 36, with a range of 73 years. The mean (EM) was 70.34 days (43.49), 65 with a median rank of 182 days. The average weight of the DRG was 4.658 (4.99) with a range that varied between 0,51–20,04. The number of patients considered outliers, as specific DRG group was 302, with an average of 30.3 patients annually outliers. Results. Acute spinal cord injured patients are classified mostly with a surgical DRG, the most frequent spinal interventions. But the greatest cost is generated by tracheotomy GRD (GRD 483-541-542) with a mass 3.7 times the average weight of our sample. Conclusions. These are usually classified GRDs surgical. But we believe that this classification does not account for the functionality that these patients have (AU)

Análisis de los factores que influyen en el gasto sanitario de los lesionados medulares agudos mediante los grupos relacionados diagnósticos / Analysis to the factors influencing the health-care costs for acute spinal cord injury by diagnosis-related groups

Objetivo. Analizar los factores que influyen en el gasto sanitario de los pacientes con lesión medular en la última década valorado a través de los grupos relacionados diagnósticos (GRD). Material y métodos. Estudio retrospectivo de pacientes dados de alta por la unidad de lesionados medulares desde el año 1997 hasta el año 2006. Se utilizan los datos obtenidos de la base de datos de los GRD de dicho hospital, que incluye los pacientes dados de alta en la unidad de lesionados medulares (n=698). El estudio investiga el número de altas, la estancia media (EM) total y el peso relativo del GRD. Se agrupó según si tenían EM normalizadas o eran outliers (pacientes con una estancia hospitalaria mayor que la media), y se estudiaron las mismas variables. Se realizó un estudio bivariable con el paquete estadístico SPSS® 15. Resultados. La EM fue de 70,3 días. El peso del GRD era de 4,65. La comparación de la EM de los outliers y no outliers mostró diferencias significativas (p<0,05). Existe una correlación entre la EM y el peso del GRD anual (–0,75). Existen 302 outliers. En los últimos 2 años ha habido un descenso importante en el número de outliers. Conclusiones. Descenso de la EM en los últimos años sin cambios en cuanto a la incidencia de ingresos, pero sí en el modelo de atención de la lesión medular aguda. Se ha producido un incremento del peso del GRD anual. Ha habido un descenso importante en el número de outliers en los últimos años (AU)

Objective. To analyze the factors influencing the health-care costs of the patients spinal cord injury in the last decade, valued through the Diagnosis-Related Groups (DRG). Material and methods. A retrospective study of given discharged patients by Spinal Cord Unit following 1997 to 2006. The collected data of the data base of the DRG are used of this hospital, and that includes the given discharged patients in the Spinal Cord Injury unit (ULM) (N=698). The study investigates the number of discharges, the mean of long of stay (LOS) and relative weight DRG's. It was grouped according to if they had LOS standardized or they were outliers, and the same variables studied. It was analyzed using a bivariate study with the statistical package SPSS® 15. Results. The LOS was 70.3 days. Weight DRG was 4,65. The comparison of LOS between of outliers and not outliers patients did not show significant differences (p<0,05). It exists a correlation between the LOS and weight DRG. The outliers were 302. In the last 2 years there has been an important reduction in the number of outliers. Conclusions. Decrease LOS in the last years, without changes as far as the incidence of SCI, but in the model of attention of the SCI patients. An increase of the weight of the annual DRG has taken place. There were important reductions in the number of outliers in the last years (AU)

[Quality of life evaluation in spinal cord injured patients comparing different bladder management techniques]. / Evaluación de la calidad de vida en pacientes con lesión medular comparando diferentes métodos de vaciado vesical.

OBJECTIVES: This study examines quality of life among patients with spinal cord injury requiring bladder management techniques, according to the validated King s Health Questionnaire (KHQ). MATERIAL AND METHODS: Prospective and observational study of 91 spinal cord-injured patients (21 women 23% and 70 men 77%). Mean age was 40 years (SD 13.4) and average time since spinal injury was 11.4 (SD 10.4) years. Patients completed the KHQ quality of life instrument and 10 additional questions related to urinary disturbance developed for the study, and filled in a form to subjectively rank their main concerns related to spinal injury. Patients were divided according to the bladder management techniques they regularly used: intermittent catheterization, condom catheter or indwelling catheter, and differences between the mean groups were assessed with de SPSS 13.0 statistic package. RESULTS: The overall KHQ score for the sample was 39.9 (SD 54.4) with higher scores (poorer QoL) in patients using an indwelling catheter. A thorough analysis of the test showed no significant differences between the groups other than in the physical role limitation item (p

Evaluación de la calidad de vida en pacientes con lesión medular comparando diferentes métodos de vaciado vesical / Quality of life evaluation in spinal cord injured patients comparing different bladder management techniques

Material y métodos: Estudio observacional y prospectivo con 91 pacientes (21 mujeres 23%, 70 hombres 77%) afectos de lesión medular que acudieron a la consulta durante marzo 2004 y diciembre del 2005, con media de edad 40 años (DS 13,4) y tiempo medio de evolución de la lesión 11,4 (DS 10,4) años. Los pacientes completaron el KHQ, así como una valoración subjetiva de los principales problemas relacionados con la lesión medular. Se clasificaron los pacientes en función del sistema de evacuación urinaria habitual en: Cateterismos Intermitentes (CI), Sondaje Vesical Permanente (SVP) y Colector Permanente (CP). Analizamos con el paquete estadístico SPSS 12.0 las diferencias entre las medias de las dimensiones del KHQ de los tres grupos. Resultados: La media de la puntuación total del KHQ fue de 39,9 puntos (DT 54,4), con mejor puntuación en el grupo portador de CP. Encontramos que no hay diferencias significativas, excepto en la dimensión de la limitación de los roles, donde obtienen mejor puntuación el grupo portador de CP que los de SVP y los CI (p=0,025).La sexualidad se presenta en primer lugar en la lista de problemas que más preocupa a los pacientes, seguidos de los trastornos de defecación y urinarios. Conclusión: El grupo con mejor puntuación global en el KHQ es el portador de CP, aunque no hay diferencias significativas entre los 3 grupos. Lo que más preocupa a nuestros pacientes son los problemas sexuales (AU)

Material and methods: Prospective and observational study of 91 spinal cord-injured patients (21 women 23% and 70 men 77%). Mean age was 40 years (SD 13.4) and average time since spinal injury was 11.4 (SD 10.4) years. Patients completed the KHQ quality of life instrument and 10 additional questions related to urinary disturbance developed for the study, and filled in a form to subjectively rank their main concerns related to spinal injury. Patients were divided according to the bladder management techniques they regularly used: intermittent catheterization, condom catheter or indwelling catheter, and differences between the mean groups were assessed with de SPSS 13.0 stadistic pakagge. Results: The overall KHQ score for the sample was 39.9 (SD 54.4) with higher scores (poorer QoL) in patients using an indwelling catheter. A thorough analysis of the test showed no significant differences between the groups other than in the physical role limitation item (p=0.025). Patients using a condom catheter reported lower physical limitation scores (better QoL) than patients using an indwelling catheter or intermittent catheterization. Sexuality was the main concern of most patients, followed by bowel dysfunction, urinary incontinence and ambulation or gait problems. Conclusion: Patients treated with condom catheters reported the best quality of life according to KHQ scores, although there were no significant differences versus the other urinary management techniques. The patients’ main concern was related to sexuality (AU)

Mapa de conflictos éticos intrahospitalarios en rehabilitación / Map of ethical conflicts at health care hospital in the medical rehabilitation

Objetivo: Analizar los principales problemas que la ciencia, la tecnología y los cambios organizativos han causado en la actividad profesional, social, asistencial, organizativa y legal de los profesionales de rehabilitación. Material y método: El estudio comprendió a 83 profesionales sanitarios que atienden a pacientes que precisan tratamiento de rehabilitación: 35 médicos de rehabilitación (24 médicos especialistas con régimen estatutario y 11 MIR [médicos internos residentes] de rehabilitación), 48 diplomadas en enfermería (DUE): 16 de la Unidad de Lesionados Medulares, 16 de la Unidad de Cuidados Intensivos y 16 de las plantas de hospitalización general, no de urgencias. Se diseñaron 2 cuestionarios de valoración, uno basado en los 10 dilemas o conflictos éticos acreditados como más habituales en el desarrollo de la actividad asistencial y otro segundo basado en los conflictos expresados en diferentes áreas: profesional, social, asistencial, organizativa y legal. Resultados: No existen diferencias significativas entre los 2 grupos (DUE versus médicos) en relación con las variables de las áreas profesional, social y legal, pero sí en la asistencial y organizativa donde se mostraron diferencias significativas entre los 2 grupos (p<0,05): los médicos presentaron más conflictos que las DUE. No existen diferencias significativas entre los 2 grupos estudiados, médicos y DUE, para la puntuación global de los 10 dilemas. Conclusiones: Antes, la solución de los problemas éticos era competencia sólo del médico, hoy lo es también del resto de los profesionales de la salud, porque todos interaccionan con el paciente, por eso la ética es una construcción social y cultural que debe revisarse constantemente en las organizaciones asistenciales, para que sus procesos conlleven a mejorar la calidad de vida de la persona con discapacidad y promover su independencia, que ha sido el objeto del presente estudio (AU)

Objective: To analyze the ethical problems in the health care of the medical and nursing rehabilitation. Materials and methods: The sample were 83 health workers, 35 doctors and 48 nurse specialists. Materials and methods: Using two assessment scales, one of the 10 ethical dilemmas and conflicts the most important during health care and a second questionnaire where was studied professionals problems, social, medical care, organizational and legal. Results: There are not significant differences between the two groups (Physician and nurse) in the variables of the areas professional, social and legal, but there were differences in the care and organizational (p<0.05), presenting doctors more conflicts than nurses. There are not significant differences between the two groups for the 10 ethical dilemmas. Conclusion: The resolution of ethical problems was only the responsibility of the physician before, but now it is also other health professional, because all of us interact with the patient. For this reason the ethics is social and cultural construction which has to constantly revise with organizations aid. For their processes improve the quality of life of people with disabilities and promote their independence, which has been the goal of this study (AU)

Aprender y enseñar en rehabilitación / Learning and teaching in rehabilitation

Objetivo. Analizar qué metodología formativateórica podría dar mejores resultados en el aprendizaje,habilidades clínicas, conocimientos teóricos adquiridos yutilidad en la vida laboral en los MIR en medicina física y rehabilitación(MFR).Material y método. Estudio longitudinal prospectivo, realizadodurante las clases del programa formativo de residentes2006-2007, con la participación de los MIR en MFR. Alfinalizar las clases se administró un cuestionario para valorarel modelo de clase (magistral e interactivo). Valoraba elaprendizaje, la habilidad, el conocimiento y la vida laboralbajo la percepción del residente. La hipótesis era que elmodelo interactivo daba mayor satisfacción en los camposde aprendizaje, habilidades, conocimiento y vida laboral queel modelo magistral. Se realizó un estudio bivariante con elpaquete estadístico SPSS® 15.Resultados. De los 189 cuestionarios, 95 se consideranclases magistrales y 94 clases interactivas. No existen diferenciasentre aprendizaje y modelo de clase. Existe asociaciónentre habilidades y modelos de clase a favor delmodelo interactivo (desacuerdo 8,7 frente a 91,3 %, parcial43,9 frente a 56,1 % y de acuerdo 61,5 frente a 50,3 %). Existeasociación entre conocimiento y modelos de clase a favordel interactivo (desacuerdo 9,1 frente a 90,9 %, parcial35,6 frente a 64,4 % y de acuerdo 62,3 frente a 37,7 %). Existeasociación entre utilidad de la vida laboral y modelos declase, a favor del interactivo (desacuerdo 18,2 frente a81,8 %, parcial 29,1 frente a 70,9 % y de acuerdo 66,1 frentea 33,9 %).Conclusión. El modelo interactivo da mejores resultadosen habilidades, conocimiento y utilidad de la vida laboral,pero no en el aprendizaje(AU)

Objective. To determine what type of theoreticaltraining methodology for residents in Physical Medicineand Rehabilitation (PM&R) provides better results forlearning, attaining clinical skills and knowledge, and relevanceto professional life.Material and methods. Prospective longitudinal study, performedduring the 2006-2007 resident training program inPM&R. At the end of each class, a questionnaire designedfor the study was distributed to residents for their evaluationof the class model (lecture-based master class or interactiveclass) as related to learning, clinical skills, knowledge,and professional life. The hypothesis was that the interactiveclass would give better satisfaction in these areas thanthe master model. Qualitative values were compared usingchi-square distributions.Results. Among the 183 questionnaires administered,50.3 % were for master classes and 49.7 % for interactiveclasses. For the recodified question on learning (We gainedknowledge in this class) 48.6 % agreed for the master classmodel and 51.4 % for the interactive model. For skills, positiveresponses were 38.5 % and 61.5 %, respectively; forknowledge, 37.7 % and 62.3 %, respectively; and for professionallife, 33.9 % and 66.1 %, respectively. There were noassociations between learning and type of class. There was,however, an association between skills, knowledge and professionallife with class model (p < 0.05), such that the interactivemodel gave better results than the master class.Conclusion. According to the subjective opinion of PM&Rmedical residents, the interactive teaching method providesa better outcome for acquisition of clinical skills, knowledge,and usefulness in clinical practice, but does not differfrom lecture-based methods for learning(AU)

Validación al castellano del Wheelchair Users Shoulder Pain Index (WUSPI) / Validation to Spanish of the Wheelchair Users Shoulder Pain Index (WUSPI)

Introducción. El interés por los trastornos del hombro en el lesionado medular es relativamente nuevo y se debe a la mayor supervivencia de esta población en los últimos 50 años1. Durante nuestra práctica diaria, nos encontramos con relativa frecuencia pacientes con un dolor de hombro que necesita ser objetivado. Para esto hemos validado el cuestionario Wheelchair Users Shoulder Pain Index (WUSPI). Material y métodos. Se realizó la traducción y adaptación del cuestionario al castellano según el método de traducción directa e inversa. Administramos dicho cuestionario a 42 pacientes entre julio de 2005 y noviembre de 2006. Finalmente, para determinar la fiabilidad y validez del nuevo cuestionario se efectuaron una serie de pruebas estadísticas. Resultados. Obtuvimos un resultado de 0,88 en el alfa de Cronbach que puede considerarse adecuado al objetivo del estudio. Conclusión. Una vez validado el Wheelchair Users Shoulder Pain Index, creemos que es importante que se le administre a todo paciente usuario de silla de ruedas que presente dolor de hombro

Introduction. Interest about shoulder disorders in people with spinal cord injury is relatively new due to increased survival of that population in the last 50 years. During our daily practice, we frequently find patients with shoulder pain that needs to be objectified. Thus, we have validated the Wheelchair Users Shoulder Pain Index (WUSPI) questionnaire. Material and methods. The questionnaire was translated and adapted into Spanish using direct and reverse translation. It was administered to 42 patients from July 2005 to November 2006. Finally, in order to determinate the reliability and validity of the new questionnaire, a series of statistical tests were performed. Results. A score of 0.88 was obtained for Cronbach's alpha that can be considered adequate for the purposes of the study. Conclusions. Having validated the Wheelchair Users Shoulder Pain Index, we believe that it should be administered to all wheelchair users with shoulder pain

[Is it too late to start orthopedic treatment for idiopathic scoliosis with Risser scores of 4?]. / Est-il trop tard pour entreprendre un traitement orthopédique pour scoliose idiopathique à Risser 4 ?

Orthopaedic treatment for idiopathic scoliosis in adolescence is indicated with a curve of > or =20 degrees and a Risser score< or =4, because progression of curve is low with Risser scores >4. We present the case of a young man with a left lumbar idiopathic scoliosis (T12-L4) with a curve of 10 degrees, which was stable from 13 years (Risser 0) to 16 years old (Risser 4). The scoliosis progressed quickly after a Risser score of 4 was achieved. The man had been wearing a lift on the left foot since he was 13, because of a leg length discrepancy, and had been under clinical and radiological monitoring. When the boy reached 17 years, the scoliosis rapidly progressed, to a curve of 22 degrees and a Risser score of >4. The scoliosis was effectively treated with a Boston brace. At 20 years, the Risser score was 5, and the left lumbar curve was 13 degrees after discontinuing the use of the brace. To our knowledge, no scientific reference indicates a time limit to orthopaedic treatment for idiopathic adolescent scoliosis. Despite the experts' recommendations, a brace might be indicated with a Risser score > or =4 to stop the progression of the curve.

Satisfacción de los pacientes con cervicalgia y lumbalgia en un servicio de rehabilitación / Satisfaction of patients with cervical pain and low back pain in a rehabilitation service

Fundamento. Son objetivos del presente trabajo: reducir el tiempo de espera para iniciar tratamiento de pacientes con lumbalgia/cervicalgia; conocer el grado de satisfacción de los pacientes al ser tratados mediante terapia en grupo; y determinar si existe correlación entre la satisfacción global, mejora del dolor e impacto sobre las actividades de la vida diaria.Material y métodos. Estudio prospectivo observacional. Población a estudio: usuarios de las consultas de un hospital terciario y del centro de especialidades adscrito al mismo, que acudieron por dolor cervical/lumbar y que modificaron una serie de ejercicios en grupo. Período de estudio: del 1 de octubre de 2001 al 1 de abril de 2002. El instrumento de medida para valorar el dolor y discapacidad fue el cuestionario Von Korff del dolor lumbar, realizándose una adaptación del mismo para el dolor cervical. Análisis estadístico: test no paramétrico de Wilcoxon.Resultados. Total de pacientes 273 (176 cervicalgias y 97 lumbalgias): 198 mujeres y 75 hombres. Edad media: 48,5 (20-81). La valoración subjetiva de los pacientes tratados en grupo mejoró en 72 sujetos (p<0,0001) con cervicalgia y en 33 (p<0,001) con lumbalgia. El dolor post-tratamiento fue significativamente mejor (p<0,001) que el pre-tratamiento en ambos grupos. Su influencia en las actividades de la vida diaria no alcanzó significación estadística. La percepción de la información recibida fue positiva en el grupo cervical (p<0,05).Conclusiones. Tras la aplicación de diversas técnicas: disminuye el volumen y el tiempo de espera –determinantes de la satisfacción de estos pacientes–; se logra una buena aceptación del tratamiento grupal, mejorando el dolor. El grado de conocimiento sobre su patología sólo mejoró en el grupo cervical

Background. The aims of the present paper are: to reduce waiting time for treatment of patients with low back pain/cervical pain; to determine the degree of satisfaction of patients being treated by groups; and to determine whether there is correlation amongst satisfaction, improvement of pain and impact on the activities of everyday life.Methods. Prospective observational study. Study population: users of the surgeries of a tertiary hospital and the specialties center attached to it, who attended surgery because of cervical/low back pain, and practiced a serie of exercises. Period of study: 1 october 2001 to 1 April 2002. The instrument of measurement used for evaluating pain and disability was the Von Korff questionnaire for low back pain, with an adaptation of this questionnaire for cervical pain. Statistical analysis: Wilcoxon’s non-parametric test.Results. Total number of patients 273 (176 with cervical pain and 97 with low back pain): 198 women and 75 men. Average age: 48.5 (20-81). The self perceived evaluation of the patients treated in a group improved in 72 subjects (p<0.0001) with cervical pain and in 33 (p<0.001) with low back pain. Post-treatment pain was significantly better (p<0.001) than pre-treatment pain in both groups. Its influence on the activities of everyday life did not achieve statistical significance. Perception of the information received was positive in the cervical group (p<0.05).Conclusions. Following the application of different techniques: reduction in number of patients and waiting time – decisive factors in the satisfaction of these patients; a good acceptance of group treatment was obtained, ameliorating pain. The degree of knowledge of their pathology only improved in the cervical group

Rotura traumática de aorta en paciente con lesión medular aguda. Tratamiento intravascular. A propósito de un caso / Traumatic rupture of the aorta in patients with acute spinal cord lesion. Endovascular treatment. A case report

Introducción. La lesión de aorta debida a traumatismo se presenta entre el 10-20 % de los politraumatizados graves. El objetivo del presente caso clínico es describir el procedimiento diagnóstico y las opciones terapéuticas de una rotura traumática de aorta en un sujeto con lesión medular. Paciente y métodos. Mostramos el caso de un paciente politraumatizado, que sufrió un accidente de moto, presentando una lesión medular a nivel sensitivo motor D1 derecha, C8 izquierda, American Spinal Card Injury Association (ASIA) A, producida por una hernia discal posteromedial C6-C7 además de un seudoaneurisma traumático de aorta. Tras ser intervenido de raquis, permaneció en la unidad de cuidados intensivos (UCI) por insuficiencia respiratoria e ingresó en planta con el diagnóstico de lesión medular incompleta ASIA B, nivel sensitivomotor C7. Discusión. Se decidió como tratamiento la colocación de una endoprótesis, lo que disminuyó los riesgos de morbimortalidad añadidos a la lesión medular, considerándose el método de elección en este tipo de pacientes

Introduction. The lesion of the aorta due to traumatism occurs in between 10 %-20 % of the serious multitraumatized patients. The objective of this clinical case is to describe the diagnostic procedure and therapeutic options of traumatic rupture of the aorta in a subject with spinal cord lesion. Patient and methods. We present the case of a multi-traumatized patient who suffered a motorcycle accident. He had a spinal cord lesion on motor sensory level right D1, left C8, ASIA A, produced by posteromedial disk herniation C6-C7 in addition to a traumatic pseudoaneurysm of the aorta. After the columna spinal was operated on, he remained in the ICU due to respiratory failure and was admitted to the ward with the diagnosis of ASIA B incomplete spinal cord lesion, C7 motor sensory level. Discussion. It was decided to place an endoprothesis as treatment. This decreased the morbidity-mortality risks added to the spinal cord lesion and was considered the method of choice in these types of patients

[A comparative study of fibromyalgia treatment: ultrasonography and physiotherapy versus sertraline treatment]. / Etude comparative dans traitement de la fibromyalgie: ultrasons et kinésithérapie versus sertraline.

OBJECTIVE: To compare the efficacy of sertraline versus physical therapy (ultrasonography and physical therapy) in fibromyalgia. DESIGN: A 6-month comparative, prospective, randomised study of 70 female patients, aged 42 to 52, with fibromyalgia according to the criteria of the American College of Rheumatology. One group (N=36) underwent 6-month treatment with sertraline, 50 mg/24 h. The other group (N=34) received 15 sessions of 1 W/cm2 ultrasonography on the cervical trigger points plus physical therapy. Variables analyzed on a visual 10-point scale were pain and morning stiffness and sleep disorders by use of the sleep questionnaire of the Medical Outcome Study (MOS). Measurements were taken at the beginning of the study and at 3-month and 6-month follow-up. RESULTS: Pain significantly diminished in the sertraline group during the entire study (visual numeric scale: 7.2+/-1.1 initially, 5.3+/-?? at 3 months and 3+/-0.7 at 6 months, P<0.05). Morning stiffness and sleep disorder scores were positive only for the sertraline group during the entire 6 months (P<0.05). Results from the MOS questionnaire showed improvement only for the sertraline group. Of the Sertraline group, 83% evaluated the treatment as good or very good, as compared with only 6% of the ultrasonography group. No patient withdrew from the study. CONCLUSION: Patients treated with sertraline had a better outcome in terms of pain, morning stiffness and sleep disorders, than the group treated with ultrasonography and physical therapy.

[Satisfaction of patients with cervical pain and low back pain in a rehabilitation service]. / Satisfacción de los pacientes con cervicalgia y lumbalgia en un servicio de rehabilitación.

BACKGROUND: The aims of the present paper are: to reduce waiting time for treatment of patients with low back pain/cervical pain; to determine the degree of satisfaction of patients being treated by groups; and to determine whether there is correlation amongst satisfaction, improvement of pain and impact on the activities of everyday life. METHODS: Prospective observational study. STUDY POPULATION: users of the surgeries of a tertiary hospital and the specialties center attached to it, who attended surgery because of cervical/low back pain, and practiced a serie of exercises. PERIOD OF STUDY: 1 october 2001 to 1 April 2002. The instrument of measurement used for evaluating pain and disability was the Von Korff questionnaire for low back pain, with an adaptation of this questionnaire for cervical pain. STATISTICAL ANALYSIS: Wilcoxon's non-parametric test. RESULTS: Total number of patients 273 (176 with cervical pain and 97 with low back pain): 198 women and 75 men. Average age: 48.5 (20-81). The self perceived evaluation of the patients treated in a group improved in 72 subjects (p<0.0001) with cervical pain and in 33 (p<0.001) with low back pain. Post-treatment pain was significantly better (p<0.001) than pre-treatment pain in both groups. Its influence on the activities of everyday life did not achieve statistical significance. Perception of the information received was positive in the cervical group (p<0.05). CONCLUSIONS: Following the application of different techniques: reduction in number of patients and waiting time - decisive factors in the satisfaction of these patients; a good acceptance of group treatment was obtained, ameliorating pain. The degree of knowledge of their pathology only improved in the cervical group.