Management of urinary incontinence after radical cystectomy and orthotopic neobladder: A scoping review of international practices.

OBJECTIVES: To identify and describe international practice in incontinence management after radical cystectomy and orthotopic neobladder. MATERIALS AND METHODS: A systematic scoping review following the methodology of the Joanne Briggs Institute was conducted in which the application searched 15 data sources to identify papers published in English, from 1979 to 2022. RESULTS: Of the 16 papers that met the eligibility criteria, articles in Eastern countries mainly focus on the effect of conservative treatment, while in Western countries, more attention is paid to the effect of surgical treatment. Clinical characteristics of patients included conservative treatment failure, duration of post-operative intervention and unique differential treatment of male and female patients. Reported factors influencing the achievement of urinary incontinence (UI) include lack of evidence to guide management practice, limited value of conservative treatment, high risk of surgical treatment and uncertainty of efficacy; currently, early behavioural research and multimodal rehabilitation training have good results. CONCLUSIONS: UI in neobladder patients is a distressing condition that is difficult to treat and often requires high-quality rehabilitation guidance and surgical intervention. Further research to address current knowledge gaps is important to inform practice.

Effect on orofacial pain in patients with chronic pain participating in a multimodal rehabilitation programme - a pilot study.

OBJECTIVES: Orofacial pain in patients taking part in a multimodal rehabilitation programme (MMRP) due to chronic bodily pain is common but it is not known whether such a rehabilitation programme can also have an effect on the presence of orofacial pain. The first aim of this study was to evaluate the effect of an MMRP on orofacial pain frequency. The second aim was to evaluate differences in the effect on quality of life and on psychosocial factors related to chronic pain. METHODS: MMRP was evaluated through validated questionnaires from the Swedish Quality Registry for Pain Rehabilitation (SQRP). Fifty-nine patients participating in MMRP filled out the two screening questions for orofacial pain in addition to the SQRP questionnaires before and after participation in MMRP during the period August 2016 to March 2018. RESULTS: Pain intensity decreased significantly after the MMRP (p=0.005). Fifty patients (69.4 %) reported orofacial pain before MMRP and no significant decrease after the programme (p=0.228). Among individuals with orofacial pain, the self-reported level of depression decreased after participation in the programme (p=0.004). CONCLUSIONS: Even though orofacial pain is common among patients with chronic bodily pain, participation in a multimodal pain programme was not enough to reduce frequent orofacial pain. This finding implies that specific orofacial pain management including information about jaw physiology could be a justified component of patient assessment prior to a multimodal rehabilitation programme for chronic bodily pain.

Sickness Absence and Disability Pension Among Patients With Chronic Pain in Interdisciplinary Treatment or Unspecified Interventions.

Interdisciplinary treatment is a widely implemented strategy for the rehabilitation of patients with chronic pain. A primary treatment objective is to decrease the load on the social insurance system; however, it is questionable whether interdisciplinary treatment reduces sickness absence and disability pension (SA/DP). This register-based observational study compared SA and DP between patients in interdisciplinary treatment and unspecified interventions. With data from 7,752 Swedish specialist health care patients in their prime working age, we analyzed total net SA/DP days over 3 years from the first visit to a pain rehabilitation center. A zero-one-inflated beta model, adjusted for theoretically substantiated confounders, was used to estimate the mean differences in total days and the proportions of patients with both zero and maximum days. Compared with unspecified interventions, interdisciplinary treatment resulted in a mean (95% confidence interval) absolute increase of 50 (37, 62) total days, a 13.0% (11.3%, 14.6%) decrease in patients with zero days, and a 1.5% (.2%, 2.8%) decrease in patients with the maximum days. These findings support that interdisciplinary treatment increases SA/DP compared to less intensive interventions but reduces the risk of maximum days, implying that it is advantageous for patients with the highest absence. This highlights the need for improved patient selection procedures and the adaptation of interdisciplinary treatment programs to more adequately target SA/DP reduction. PERSPECTIVES: This study provides an accessible overview of SA/DP among working-age patients with chronic pain in Swedish specialist health care. It also shows that interdisciplinary treatment does not decrease SA/DP more than alternative treatments in most patients but is advantageous for the patients with the longest absence.

Precision neuromodulation: Promises and challenges of spinal stimulation for multi-modal rehabilitation.

Spinal cord injury results in multiple, simultaneous sensorimotor deficits. These include, but are not limited to, full or partial paralysis of muscles below the lesion, muscle spasms, spasticity, and neuropathic pain. Bowel, bladder, and sexual dysfunction are also prevalent. Yet, the majority of emerging spinal stimulation-based therapies focus on a single issue: locomotor rehabilitation. Despite the enormous potential of these translational advances to transform the lives of people living with spinal cord injury, meaningful recovery in other domains deemed critical priorities remains lacking. Here, we highlight the importance of considering the diverse patterns of neural transmission that underlie clinically similar presentations when developing spinal stimulation-based therapies. We also motivate advancement of multi-modal rehabilitation paradigms, which leverage the dense interconnectivity of sensorimotor spinal networks and the unique ability of electrical stimulation to modulate these networks to facilitate and guide simultaneous rehabilitation across domains.

INTRODUCTION OF A MULTIMODAL PAIN REHABILITATION INTERVENTION IN PRIMARY CARE: A PILOT STUDY.

Objective: To evaluate patient-reported outcome measures in patients with chronic musculoskeletal pain 1 year after participation in a case manager-led multimodal rehabilitation intervention in a Finnish primary care centre. Changes in healthcare utilization (HCU) were also explored. Methods: A prospective pilot study with 36 participants. The intervention consisted of screening, multidisciplinary team assessment, a rehabilitation plan and case manager follow-up. Data were collected through questionnaires filled in after the team assessment and 1 year later. HCU data 1 year before and 1 year after team assessment were compared. Results: At follow-up, satisfaction with vocational situation, self-reported work ability and health-related quality of life (HRQoL) had improved and pain intensity had diminished significantly for all participants. The participants who reduced their HCU improved their activity level and HRQoL. Early intervention by a psychologist and mental health nurse was distinctive for the participants who reduced HCU at follow-up. Conclusion: The findings demonstrate the importance of early biopsychosocial management of patients with chronic pain in primary care. Identification of psychological risk factors at an early stage may lead to better psychosocial wellbeing, improve coping strategy and reduce HCU. A case manager may free up other resources and thereby contribute to cost savings.

The effects of cognitive, physical, and somatosensory rehabilitation after right temporo-parietal tumor resection on cognitive, motor, somatosensory, and electrophysiological parameters: A case report.

INTRODUCTION: This report examines the effects of a multimodal rehabilitation program which includes cognitive, physical, and somatosensory rehabilitation after right temporo-parietal tumor resection on cognitive, motor, somatosensory, and electrophysiological parameters. CASE DESCRIPTION: A 22-year-old patient presented with sensory loss in the dominant left hand and reduced writing ability after right temporo-parietal lobe resection. Cognitive, motor, and sensory evaluations were carried out pre and post-treatment. The patient's spontaneous electroencephalo-gram (EEG) and an EEG during application of transcutaneous electrical nerve stimulation (TENS) (TENS EEG) were recorded. As a reference for the patient's electrophysiological values, EEGs of 4 healthy individuals were also taken. Over a period of 1 year, the patient received multimodal rehabilitation which includes cognitive, physical, and somato-sensory rehabilitation on 2 days each week. OUTCOMES: An improvement of the patient's cognitive capacities, motor strength, superficial, deep and cortical sensations was achieved. After rehabilitation, an increase in parietal and occipital alpha activity as well as in frontal and parietal beta activity was seen both in spontaneous EEG and in TENS EEG. With increasing TENS intensity, alpha and beta power increased as well. CONCLUSION: Our findings suggest that a multimodal rehabilitation program may improve cognitive, sensory, and motor effects after resection due to tumor surgery.

Components of primary care multimodal rehabilitation and their association with changes in sick leave: An observational study.

BACKGROUND: To address the increase in sick leave for nonspecific chronic pain and mental illness, the Swedish government and the Swedish Association of Local Authorities and Regions entered into an agreement on a "Rehabilitation Guarantee" to carry out multimodal rehabilitation (MMR). OBJECTIVE: To investigate whether components of primary care MMR are associated with changes in sick leave. METHODS: A web-based survey was conducted in conjunction with a retrospective cross-sectional observational study of 53 MMR units. Sick leave data for the years before and after MMR completion was collected for 846 individuals. RESULTS: There was great disparity in how MMR was delivered. The average duration of rehabilitation was 4-8 weeks, and 74% of the MMR teams reported having fewer patients than recommended (≥20/year). Only 58% of the teams met the competence requirements. In-depth competence in pain relief and rehabilitation was reported by 45% of the teams and was significantly associated with fewer sick leave days after MMR (26.53, 95% CI: 3.65; 49.42), as were pain duration (17.83, 95% CI: -9.20; 44.87) and geographic proximity (23.75, 95% CI: -5.25; 52.75) of the health care professionals included in the MMR unit. CONCLUSIONS: In-depth competence and knowledge about the complex health care needs of patients seem essential to MMR teams' success in reducing sickness benefits for patients with nonspecific chronic pain and mental illness. Further research is needed to elucidate the optimal combination of primary care MMR components for increasing the return-to work rate and to determine whether involvement of the Social Insurance Agency or employers could support and further contribute to recuperation and help patients regain their previous work capacity.

Combining exercise, protein supplementation and electric stimulation to mitigate muscle wasting and improve outcomes for survivors of critical illness-The ExPrES study.

BACKGROUND: Neuromuscular electrical stimulation (NMES) with high protein supplementation (HPRO) to preserve muscle mass and function has not been assessed in ICU patients. We compared the effects of combining NMES and HPRO with mobility and strength rehabilitation (NMES+HPRO+PT) to standardized ICU care. OBJECTIVES: To assess the effectiveness of combined NMES+HPRO+PT in mitigating sarcopenia as evidenced by CT volume and cross-sectional area when compared to usual ICU care. Additionally, we assessed the effects of the combined therapy on select clinical outcomes, including nutritional status, nitrogen balance, delirium and days on mechanical ventilation. METHODS: Participants were randomized by computer generated assignments to receive either NMES+HPRO+PT or standard care. Over 14 days the standardized ICU care group (N = 23) received usual critical care and rehabilitation while the NMES+HPRO+PT group (N = 16) received 30 min neuromuscular electrical stimulation of quadriceps and dorsiflexors twice-daily for 10 days and mean 1.3 ± 0.4 g/kg body weight of high protein supplementation in addition to standard care. Nonresponsive participants received passive exercises and, once responsive, were encouraged to exercise actively. Primary outcome measures were muscle volume and cross-sectional area measured using CT-imaging. Secondary outcomes included nutritional status, nitrogen balance, delirium and days on mechanical ventilation. RESULTS: The NMES+HPRO+PT group (N = 16) lost less lower extremity muscle volume compared to the standard care group (N = 23) and had larger mean combined thigh cross-sectional area. The nitrogen balance remained negative in the standard care group, while positive on days 5, 9, and 14 in the NMES+HPRO+PT group. Standard care group participants experienced more delirium than the NMES+HPRO+PT group. No differences between groups when comparing length of stay or mechanical ventilation days. CONCLUSIONS: The combination of neuromuscular electrical stimulation, high protein supplementation and mobility and strength rehabilitation resulted in mitigation of lower extremity muscle loss and less delirium in mechanically ventilated ICU patients. TRIAL REGISTRATION: Clinicaltrials.gov identifier: NCT02509520. Registered July 28, 2015.

Comparison of Rehabilitative Interventions That Ameliorate Post-stroke Working Memory Deficit: A Systematic Review.

Stroke is one of the most common causes of disability in the world. It has sensory, motor, and cognitive symptoms. Many cognitive domains might get involved in a stroke. This systematic review focuses on working memory domain deficits after stroke and their various rehabilitation methods. This review is based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses(PRISMA) guidelines. For this review, we have searched PubMed, Google Scholar, and Science Direct databases and screened thoroughly with the inclusion criteria of free full-text English papers in the last 10 years that have exclusively studied humans. The articles included in the search are randomized control trials (RCTs), observational studies, meta-analysis studies, systematic reviews, and traditional reviews. Consequent quality assessment was done using the most commonly used tools for each type of study and eight papers were selected. From these papers, full-text articles were studied, analyzed, and tabulated. We found five different rehabilitation methods: transcranial direct-current stimulation, computer-assisted cognitive rehabilitation, physical activity, goal setting, and multimodal rehabilitation. We found that goal setting, computer-assisted cognitive rehabilitation, and multimodal rehabilitation can improve working memory deficits. While transcranial direct current stimulation and physical activity were inconsistent, further studies are needed. The small sample size, no follow-up, the inclusion of only a few studies, the size of the stroke, and comorbid conditions like mild cognitive impairment, dementia, and depression were the main limitations of this study. Future reviews must include a larger number of studies with large sample sizes, including follow-up as an inclusion criterion. We need more clinical trials on these methods for better knowledge.

Effects of Multimodal Rehabilitation on the Activities of Daily Living, Quality of Life, and Burden of Care for Patients with Parkinson's Disease: A Randomized Control Study.

Background: Parkinson's disease reduces patients' function, activities of daily living, and quality of life, and increases their guardians' burden of care. This study verified the effectiveness of a multimodal rehabilitation programme for patients with Parkinson's disease. Trial design: This study was a multicentre parallel randomised controlled, single-blind, trial conducted in three hospitals in Korea. Methods: A central randomisation centre used computer generated tables to randomly allocate 60 of 75 patients with Parkinson's disease who fulfilled the study requirements into experimental (n = 30; multimodal rehabilitation; consisting of daily living training, guardian education, home environment modification, fine muscle exercise, balance training, and training using auxiliary tools performed 50 min per session, twice a week, in 10 sessions) and control (n = 30; traditional rehabilitation; consisting of task-oriented training, joint exercise, and daily living training performed 50 min per session, twice a week, in 10 sessions) groups. Results: Multimodal rehabilitation for Parkinson's disease significantly improved the activities of daily living (p < 0.01) and quality of life of patients (p < 0.001) and eased the guardians' burden of care (p < 0.001). Conclusions: Multimodal rehabilitation is suggested to improve activities of daily living, quality of life of patients with Parkinson's disease, and reduce the burden of care of their guardians.

Reported Outcomes in Interdisciplinary Pain Treatment: An Overview of Systematic Reviews and Meta-Analyses of Randomised Controlled Trials.

Background: There is considerable diversity of outcome selections and methodologies for handling the multiple outcomes across all systematic reviews (SRs) of Interdisciplinary Pain Treatment (IPT) due to the complexity. This diversity presents difficulties for healthcare decision makers. Better recommendations about how to select outcomes in SRs (with or without meta-analysis) are needed to explicitly demonstrate the effectiveness of IPT. Objective: This overview systematically collates the reported outcomes and measurements of IPT across published SRs and identifies the methodological characteristics. Additionally, we provide some suggestions on framing the selection of outcomes and on conducting SRs of IPT. Methods: Three electronic databases (PubMed, Cochrane Library, and Epistemonikos) and the PROSPERO registry for ongoing SR were supplemented with hand-searching ending on 30 September 2021. Results: We included 18 SRs with data on 49007 people from 356 primary randomised controlled trials (RCTs); eight were followed by meta-analysis and ten used narrative syntheses of data. For all the SRs, pain was the most common reported outcome (72%), followed by disability/functional status (61%) and working status (61%). Psychological well-being and quality of life were also reported in half of the included SR (50%). The core outcome domains according to VAPAIN, IMMPACT, and PROMIS were seldom met. The methodological quality varied from critically low to moderate according to AMSTAR2. The AMSTAR2 rating was negatively correlated to the number of outcome domains in PROMIS, and VAPAIN was positively correlated with IMMPACT and PROMIS, indicating the intercorrelations between the reported outcomes. Conclusion: This systematic overview showed wide-ranging disparity in reported outcomes and applied outcome domains in SRs evaluating IPT interventions for chronic pain conditions. The intercorrelations between the reported outcomes should be appropriately handled in future research. Some approaches are discussed as well.

Recommendations of the Society of Thoracic Surgery and the Section of Cardiothoracic and Vascular Surgery of the Spanish Society of Anesthesia, Resuscitation and Pain Therapy, for patients undergoing lung surgery included in an intensified recovery program.

In recent years, multidisciplinary programs have been implemented that include different actions during the pre, intra and postoperative period, aimed at reducing perioperative stress and therefore improving the results of patients undergoing surgical interventions. Initially, these programs were developed for colorectal surgery and from there they have been extended to other surgeries. Thoracic surgery, considered highly complex, like other surgeries with a high postoperative morbidity and mortality rate, may be one of the specialties that most benefit from the implementation of these programs. This review presents the recommendations made by different specialties involved in the perioperative care of patients who require resection of a lung tumor. Meta-analyzes, systematic reviews, randomized and non-randomized controlled studies, and retrospective studies conducted in patients undergoing this type of intervention have been taken into account in preparing the recommendations presented in this guide. The GRADE scale has been used to classify the recommendations, assessing on the one hand the level of evidence published on each specific aspect and, on the other hand, the strength of the recommendation with which the authors propose its application. The recommendations considered most important for this type of surgery are those that refer to pre-habilitation, minimization of surgical aggression, excellence in the management of perioperative pain and postoperative care aimed at providing rapid postoperative rehabilitation.

Recomendaciones de la Sociedad Española de Cirugía Torácica y de la Sección de Cardiotorácica y Cirugía Vascular de la Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor, para los pacientes sometidos a cirugía pulmonar incluidos en un programa de recuperación intensificada / Recommendations of the Society of Thoracic Surgery and the Section of Cardiothoracic and Vascular Surgery of the Spanish Society of Anesthesia, Resuscitation and Pain Therapy, for patients undergoing lung surgery included in an intensified recovery program

En los últimos años se están implementando programas multidisciplinares que incluyen diferentes actuaciones durante el periodo pre, intra y postoperatorio, encaminadas a disminuir el estrés perioperatorio y, por tanto, a mejorar los resultados de los pacientes sometidos a intervenciones quirúrgicas. Inicialmente, estos programas se desarrollaron para cirugía colorrectal y de ahí se han ido extendiendo a otras cirugías. La cirugía torácica, considerada de elevada complejidad, al igual que otras cirugías con una alta tasa de morbimortalidad postoperatoria, puede ser una de las especialidades que más se beneficien de la implantación de estos programas. En esta revisión se presentan las recomendaciones elaboradas por diferentes especialidades implicadas en los cuidados perioperatorios de los pacientes que requieren la resección de un tumor pulmonar. Para la elaboración de las recomendaciones presentadas en esta guía se han tenido en cuenta los metaanálisis, las revisiones sistemáticas, los estudios controlados aleatorizados y no aleatorizados y los estudios retrospectivos realizados en pacientes sometidos a este tipo de intervenciones. Para la clasificación de las recomendaciones se ha empleado la escala GRADE, valorando, por un lado, el nivel de evidencia publicado sobre cada aspecto concreto, y por otro, la fuerza de la recomendación con la que los autores proponen su aplicación. Las recomendaciones consideradas más importantes para este tipo de cirugía son las que se refieren a la prehabilitación, a la minimización de la agresión quirúrgica, a la excelencia en el manejo del dolor perioperatorio y a los cuidados postoperatorios encaminados a proporcionar una rápida rehabilitación postoperatoria.(AU)

In recent years, multidisciplinary programs have been implemented that include different actions during the pre, intra and postoperative period, aimed at reducing perioperative stress and therefore improving the results of patients undergoing surgical interventions. Initially, these programs were developed for colorectal surgery and from there they have been extended to other surgeries. Thoracic surgery, considered highly complex, like other surgeries with a high postoperative morbidity and mortality rate, may be one of the specialties that most benefit from the implementation of these programs. This review presents the recommendations made by different specialties involved in the perioperative care of patients who require resection of a lung tumor. Meta-analyses, systematic reviews, randomized and non-randomized controlled studies, and retrospective studies conducted in patients undergoing this type of intervention have been taken into account in preparing the recommendations presented in this guide. The GRADE scale has been used to classify the recommendations, assessing on the one hand the level of evidence published on each specific aspect and, on the other hand, the strength of the recommendation with which the authors propose its application. The recommendations considered most important for this type of surgery are those that refer to pre-habilitation, minimization of surgical aggression, excellence in the management of perioperative pain and postoperative care aimed at providing rapid postoperative rehabilitation.(AU)

Investigating the Long-Term Effect of an Interdisciplinary Multimodal Rehabilitation Program on Levels of Bioactive Lipids and Telomerase Activity in Blood from Patients with Chronic Pain.

Mechanism-based diagnosis and therapies for chronic pain are lacking. However, bio-psycho-social interventions such as interdisciplinary multimodal rehabilitation programs (IPRPs) have shown to be relatively effective treatments. In this context we aim to investigate the effects of IPRP on the changes in levels of bioactive lipids and telomerase activity in plasma, and if these changes are associated with changes in pain intensity and psychological distress. This exploratory study involves 18 patients with complex chronic pain participating in an IPRP. Self-reports of pain, psychological distress, physical activity, and blood samples were collected before the IPRP and at a six-month follow-up. Levels of arachidonoylethanolamide (AEA) and 2-arachidonoylglycerol (2-AG), palmitoylethanolamide (PEA), oleoylethanolamide (OEA), stearoylethanolamide (SEA), and telomerase activity were measured. Pain intensity was decreased, and SEA levels were increased at the six-month follow up. A significant correlation existed between changes in SEA levels and pain intensity. AEA levels, were inversely correlated with physical activity. Furthermore, 2-AG and telomerase activity was significantly correlated at the six-month follow-up. This study confirms that IPRP is relatively effective for reduction in chronic pain. Changes in SEA were correlated with changes in pain intensity, which might indicate that SEA changes reflect the pain reduction effects of IPRP.

Thrombotic and hemorrhagic risk in bariatric surgery with multimodal rehabilitation programs comparing 2 reduced guidelines for pharmacological prophylaxis.

OBJECTIVE: To determine the thrombotic and hemorrhagic risk in bariatric surgery with multimodal rehabilitation programs, comparing two guidelines of pharmacological prophylaxis recommended in the Guide to the Spanish Society for Obesity Surgery and the Obesity Section of the AEC. METHODS: Cohorts retrospective study from January-2010 to December-2019. Cases of vertical gastrectomy or gastric bypass were recorded, systematically applying multimodal rehabilitation protocols. Two reduced chemoprophylaxis regimens were analyzed, starting after surgery and maintained for 10 days; one with fondaparinux (Arixtra®) at a fixed dose of 2.5mg/day and the other with enoxaparin (Clexane®) with a single daily dose adjusted to BMI: 40mg/day for BMI of 35-40 and 60mg/day for BMI 40-60. RESULTS: 675 patients were included; 354 with Fondaparinux-Arixtra® during the period 2010-2015 and 321 with Enoxaparin-Clexane® during the period 2016-2019. There were no cases of DVT or clinical PE. However, the incidence of hemorrhage requiring reoperation, transfusion, or a decrease of more than 3g/dL hemoglobin was 4.7%, with no difference between groups. Mortality was nil. The average stay was 2.8 days and the outpatient follow-up was 100% during the first 6 months and 95% at 12 months. CONCLUSIONS: The combination of multimodal rehabilitation programs and mechanical and pharmacological thromboprophylaxis by experienced teams, reduces the risk of thromboembolic events and could justify reduced chemoprophylaxis regimens to decrease the risk of postoperative bleeding.

Multimodal exercises integrated with cognitive-behavioural therapy improve disability of patients with failed back surgery syndrome: a randomized controlled trial with one-year follow-up.

PURPOSE: To evaluate the effect of multimodal exercises integrated with cognitive-behavioural therapy on disability, pain, and quality of life in patients suffering from failed back surgery syndrome (FBSS), and to appraise its extent in the long term. METHODS: By means of a parallel-group superiority-controlled trial, 150 outpatients were randomly assigned to a 10-week individual-based multimodal programme of task-oriented exercises integrated with cognitive-behavioural therapy (experimental group, 75 patients) or individual-based general physiotherapy (control group, 75 patients). Before treatment, 10 weeks later (post-treatment), and 12 months after the end of treatment, the Oswestry Disability Index (primary outcome), the Tampa Scale for Kinesiophobia, the Pain Catastrophising Scale, a pain intensity numerical rating scale and the Short-Form Health Survey were evaluated. Linear mixed model analysis for repeated measures was carried out for each outcome measure. RESULTS: Significant group (p < 0.001), time (p < 0.001), and time-by-group interaction (p < 0.001) effects were found for all outcome measures. Concerning disability, between-group differences (95% confidential interval) in favour of the experimental group of -9 (-10.7; -7.3) after training and of -13.2 (-14.7; -11.7) at follow-up were found. Also, kinesiophobia, catastrophising and pain showed significant between-group differences of 9, 12.5 and 1.7 points, respectively. CONCLUSION: The multimodal intervention proposed was superior to general physiotherapy in reducing disability, kinesiophobia, catastrophising, and enhancing the quality of life of patients with FBSS. The effects were reinforced one year after the programme ended.IMPLICATIONS FOR REHABILITATIONMultimodal exercises integrated with cognitive-behavioural therapy induced significant improvements in disability, pain, kinesiophobia, catastrophising, and quality of life of subjects with Failed Back Surgery Syndrome.A well-integrated rehabilitative team which contributes towards reaching intervention goals is advised.Physiotherapists should adopt task-oriented exercises to promote an earlier return to common activities of disabled patients.Psychologists should explain how to modify useless beliefs and support adequate behaviours, in order to produce constructive attitudes towards perceived disability.

Recommendations of the Society of Thoracic Surgery and the Section of Cardiothoracic and Vascular Surgery of the Spanish Society of Anesthesia, Resuscitation and Pain Therapy, for patients undergoing lung surgery included in an intensified recovery program. / Recomendaciones de la Sociedad Española de Cirugía Torácica y de la Sección de Cardiotorácica y Cirugía Vascular de la Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor, para los pacientes sometidos a cirugía pulmonar incluidos en un programa de recuperación intensificada.

In recent years, multidisciplinary programs have been implemented that include different actions during the pre, intra and postoperative period, aimed at reducing perioperative stress and therefore improving the results of patients undergoing surgical interventions. Initially, these programs were developed for colorectal surgery and from there they have been extended to other surgeries. Thoracic surgery, considered highly complex, like other surgeries with a high postoperative morbidity and mortality rate, may be one of the specialties that most benefit from the implementation of these programs. This review presents the recommendations made by different specialties involved in the perioperative care of patients who require resection of a lung tumor. Meta-analyses, systematic reviews, randomized and non-randomized controlled studies, and retrospective studies conducted in patients undergoing this type of intervention have been taken into account in preparing the recommendations presented in this guide. The GRADE scale has been used to classify the recommendations, assessing on the one hand the level of evidence published on each specific aspect and, on the other hand, the strength of the recommendation with which the authors propose its application. The recommendations considered most important for this type of surgery are those that refer to pre-habilitation, minimization of surgical aggression, excellence in the management of perioperative pain and postoperative care aimed at providing rapid postoperative rehabilitation.

Esofaguectomía «tubeless»: menos es más / “Tubeless” esophagectomy: Less is more

La cirugía del cáncer de esófago es un procedimiento complejo con tasas de morbimortalidad elevadas, por lo que para obtener resultados adecuados se precisa de centros experimentados, un completo soporte multidisciplinar y vías clínicas adecuadas. Se describe la experiencia inicial y la técnica de la esofaguectomía «tubeless» en la que tras realizar una resección esofágica y linfadenectomía mediastínica extendida, al final del procedimiento no son colocados drenajes ni sondas de ningún tipo, con el fin de disminuir la agresividad del mismo, mejorar el bienestar postoperatorio y acelerar la recuperación funcional del paciente. (AU)

The esophageal cancer surgery is a complex procedure with elevated rates of both morbidity and mortality, which is why, in order to achieve adequate results, it should be performed in high volume centers, where complete multidisciplinary support is available and recent clinical guidelines are applied. We describe the initial experience and the technique of “tubeless” esophagectomy where esophageal resection and mediastinal lymphadenectomy are performed and no drains nor tubes of any kind are placed, with the aim to decrease the level of surgical aggression, enhance the postoperative comfort and accelerate the patient́s recovery. (AU)

"Tubeless" esophagectomy: Less is more.

The esophageal cancer surgery is a complex procedure with elevated rates of both morbidity and mortality, which is why, in order to achieve adequate results, it should be performed in high volume centers, where complete multidisciplinary support is available and recent clinical guidelines are applied. We describe the initial experience and the technique of "tubeless" esophagectomy where esophageal resection and mediastinal lymphadenectomy are performed and no drains nor tubes of any kind are placed, with the aim to decrease the level of surgical aggression, enhance the postoperative comfort and accelerate the patient́s recovery.

Thrombotic and hemorrhagic risk in bariatric surgery with multimodal rehabilitation programs comparing 2 reduced guidelines for pharmacological prophylaxis. / Riesgo trombótico y hemorrágico en cirugía bariátrica con programas de rehabilitación multimodal comparando 2 pautas reducidas de profilaxis farmacológica.

OBJECTIVE: to determine the thrombotic and hemorrhagic risk in bariatric surgery with multimodal rehabilitation programs, comparing 2guidelines of pharmacological prophylaxis recommended in the Guide to the Spanish Society for Obesity Surgery and the Obesity Section of the AEC. METHODS: Cohorts retrospective study from January-2010 to December-2019. Cases of vertical gastrectomy or gastric bypass were recorded, systematically applying multimodal rehabilitation protocols. Two reduced chemoprophylaxis regimens were analyzed, starting after surgery and maintained for 10 days; one with fondaparinux (Arixtra®) at a fixed dose of 2.5mg / day and the other with enoxaparin (Clexane®) with a single daily dose adjusted to BMI: 40mg / day for BMI of 35-40 and 60mg/day for BMI 40-60. RESULTS: 675 patients were included; 354 with Fondaparinux-Arixtra® during the period 2010-2015 and 321 with Enoxaparin-Clexane® during the period 2016-2019. There were no cases of DVT or clinical PE. However, the incidence of hemorrhage requiring reoperation, transfusion, or a decrease of more than 3g / dL hemoglobin was 4.7%, with no difference between groups. Mortality was nil. The average stay was 2.8 days and the outpatient follow-up was 100% during the first 6 months and 95% at 12 months. CONCLUSIONS: The combination of multimodal rehabilitation programs and mechanical and pharmacological thromboprophylaxis by experienced teams, reduces the risk of thromboembolic events and could justify reduced chemoprophylaxis regimens to decrease the risk of postoperative bleeding.