[Peripheral nerves phenolisation in spasticity management - forgotten art or interesting perspective?]

INTRODUCTION: Spasticity is one of the most common obstacles in the process of rehabilitation after permanent central nervous system injury. Statistics show that the problem affects more than 12 billion people all over the world. Treatment of spasticity is necessary for proper rehabilitation, prevention of secondary disability, pain management and also strongly influences quality of life. Nowadays the most common formula used for the treatment of local spasticity is injection of botulinum toxin. Years ago and also nowadays physicians all over the world successfully used phenol as the chemodenervating factor. This technique today almost forgot in Poland but still used in other countries. MATERIALS AND METHODS: Peripheral nerves phenolisation had been used in STOCER (Konstancin) since 1965. The procedure was performed once in 59 patients, twice in 13 patients and three times in 7 patients. Evaluation was based on clinical presentation completed with patient self evaluation form. RESULTS: Good - 36 cases (45%), moderate - 34 cases (43%), bad - 9 cases (12%). CONCLUSION: Peripheral nerve phenolisation seems to be an interesting alternative to botulinum toxin in the management of spasticity.

The Influence of Pelvic Asymmetry on Trunk Symmetry Among Children.

BACKGROUND: Pelvic asymmetry and accompanying postural defects tend to become more common with age. The school period, which is associated with spending more time in a sitting position and daily activities performed with the dominant limb, may contribute to this. MATERIAL AND METHODS: We examined 22 children (12 girls, 10 boys) aged 7 years. The same group was re-examined two years later. Pelvic asymmetry was identified by assessing the position of the iliac spines. The indicator of trunk asymmetry was the trunk rotation angle (TRA) measured with a Bunnel scoliometer within the spinous processes on the upper thoracic vertebra, apex of thoracic kyphosis, thoracolumbar junction, lumbar spine, and (if present in patients) the greatest deformity (rib hump, hump in the lumbar region). RESULTS: Pelvic asymmetry was detected in 14 children at the age of 7 years compared to 16 in the same group of patients aged 9 years. During these two years, the prevalence of trunk asymmetry in children with an oblique/rotated pelvis had increased. The progression of trunk asymmetry with an oblique position of the pelvis was most marked in the lumbar region. In children with symmetrical pelvis, the most marked increase in TRA was recorded in the thoracic segment. CONCLUSIONS: 1. The development of pelvic girdle asymmetry is influenced by the increasing number of asymmetrically performed movements and asymmetric body positions assumed, which increase in number with age. 2. The most marked increase in asymmetry of the spine in subjects with an oblique/rotated pelvis was seen in the lumbar spine, which proves an association of the former with tilting of the pelvic girdle. 3. Asymmetry is a dynamic process. When ignored, this postural defect progresses significantly and there may be compensatory changes in neighbouring systems.

[Factors effecting frequency of occurrence of back pain syndromes]. / Czynniki wplywajace na czestosc wystepowania zespolów bólowych kregoslupa.

Low back pain syndromes are in the group of the commonest diseases observed in recent years and bear serious medical, social and economical burden. According to European data more than 70% of population suffered from back pain at least for a week in the lifetime, and 15-40% of population experiences low back pain every year. There is alarming decrease in the age of first onset described by many authors. Peak morbidity is observed in persons aged between 35 and 55 years, but a recent Japanese study brings evidence that 66.7% of middle-school children has already experienced low back pain lasting for at least 1 week, and relapse rate exceeds 60%. Increase of incidence and morbidity of low back pain is linked to lifestyle alterations including significant limitation of physical activities since young age, changes of hobby preferences, alteration of work habits favoring activities performed in improper body position lasting for hours or even years, to dynamic physical work. Pain may be presented in any phase of spinal overload syndromes. Back pain may result from nocyceptive activation in spinal, paraspinal tissues as well as irritating of nervous structures within vertebral canal, when appears as a neuropathic pain. Pain in spondylolisthesis may be related to ligamentous constrain, particularly when posterior longitudinal ligament (densely supplied with nocyceptive endings) is involved. The paper describes the commonest back pain syndromes and spinal deformities resulting from long-lasting overload with their typical presentation.

Scientific Idea of Professor Marian Weiss.

This year marks the 100th birth anniversary of Professor Marian Alan Weiss. The following article serves as a reminder of this magnificent man, doctor and scientist and his indisputable multifaceted accomplishments. Prof. Weiss was a brilliant organizer. He proposed and then formed the largest medical rehabilitation centre in Poland, the STOCER Capital Rehabilitation Centre in Konstantin, and established one of the first university departments of rehabilitation in Europe. His medical achievements included Weiss' spring arthroplasty, a me-thod for stabilising the spine after an injury. He also promoted myoplastic amputation and early intraoperative prosthetic support (so-called rapid prosthesis) as well as early comprehensive rehabilitation, which is widely recognized today. Prof. Weiss was a first-rate scientist and lecturer. He published more than 200 articles in Polish and international journals, a few textbooks and monographs. He delivered many lectures and presentations at domestic and international congresses and symposia. As early as 1959, he lectured at international seminars on prosthetics and rehabilitation of amputees. As an expert of the WHO Regional Bureau, he organized international training workshops on rehabilitation, with English and French as languages of instruction. He was an honorary member of the New York Physical Medicine Society, held an honorary doctorate from Rennes University and an honorary membership of the Swedish Orthopaedic Society, and received the Honorary Medal of Vishnevsky Institute in Moscow. He also was Vice-president of the "Paraplegia" International Medical Society. His unexpected death in 1961 put an end to his further organizational, professional, scientific and educational plans.

Possibilities for Quality Assessment of Health Services in Therapeutic Rehabilitation.

The main goal of therapeutic rehabilitation is to provide services that develop, maintain or restore mobility and functionality to the fullest extent possible throughout the patient's life. This process should involve setting real goals both for the person who has mobility and functionality impairment as well as in the records of relevant therapeutic programme objectives. In evaluating this process, quality indicators can be used as 'tools' and they may also be used as parameters for quantitative characterization of healthcare processes and outcomes. The purpose of this paper is to systematise existing knowledge about quality in healthcare in the context of therapeutic rehabilitation, presenting a possible assessment of the level and degree of completion of goals through quality indicators.

Strategies for neuroprotection following spinal cord injury.

Progress in neuropathology has made possible the description of local responses of neural tissue in early stages after traumatic spinal cord injury (SCI). The recent identification of multiple factors responsible for secondary spinal cord damage and for potential regenerative abilities has not resulted in the development of a standard for neuroprotective therapy in SCI patients. The paper reviews current knowledge concerning the sequence of biochemical events in the injured spinal cord and gives an overview of therapeutic possibilities for preventing the spread of secondary injury. The literature survey has led to the following conclusions: 1. The primary zone of traumatic damage enlarges due to local vascular disturbances, hypoxia, and the resulting inflammation. 2. Inflammation in the region of secondary injury, apart from having a destructive impact, is the source of substances which may induce neural tissue repair. 3. The administration of methylprednisolone and surgical decompression of the spinal cord within several hours after SCI improves functional and neurological outcomes in patients with incomplete neurological deficits. Currently there is no sufficient scientific evidence to support the safety and efficacy of other neuroprotective methods in humans.

Repair therapies in spinal cord injuries.

Spinal cord repair therapies (SCRT) are experimental treatments which are attracting a growing interest among both spinal cord injury sufferers and their families as well as physicians and physiotherapists. Basing on current professional literature, this article presents the most important SCRT strategies. The majority of currently developed SCRTs are at the stage of experimental in vitro or animal studies. Few of these studies are in the early clinical trial stage or are being offered as non-standard commercial health care services. Basing on a review of the literature, it can be stated that currently there are few studies which meet the criterion of reliability, and their results make possible an objective assessment of the safety and efficacy of SCRT. Available study results are insufficient to confirm the advisability of widespread application of these methods.

The role of rehabilitation and methodological problems in spinal cord repair therapies.

Despite the rapid development of studies of spinal cord repair therapies (SCRT), there is still a dearth of reliable reports on their clinical usefulness. Basing on a review of current literature, this article emphasises the role and special character of comprehensive rehabilitation based on the modulation of central nervous system plasticity in the treatment of spinal cord injuries with the use of SCRT. Basing on guidelines by the International Campaign for Cures of Spinal Cord Injury Paralysis (ICCP), this article also discusses ethical and methodological issues of SCRT studies. Comprehensive motor rehabilitation exerts an effect that potentially modifies spinal cord plasticity and may significantly supplement SCRT, leading to expected functional effects. Encouraging results of animal studies cannot be directly translated into expectations regarding SCRT utility people. Ensuring a high quality of studies on SCRT efficacy and safety necessitates compliance with rigorous methodological requirements. Functional ability of the patient needs to be a significant end-point of SCRT studies.

Evaluation of Local Cryotherapy after Anterior Cruciate Ligament Reconstruction. Critical Review of the Literature.

BACKGROUND: At a time of innovative medical technologies development, it is paramount that medical services be evaluated with regard to their effectiveness. Research in physical medicine and rehabilitation, as well as the specialty itself, is relatively young; however, the number of publications in the field has recently been increasing. The main aim of this article is to evaluate the effectiveness of cryotherapy, including local cryostimulation, after anterior cruciate ligament reconstruction. MATERIAL AND METHODS: The present paper reviews scientific publications extracted from the Medline Embase, Cochra-ne Library, and PEDro databases according to a pre-designed search strategy. The review analysed publications where the authors indicated cryotherapy as an intervention in patients after ACL reconstruction and the study endpoints referred to analgesic or anti-oedema effects. RESULTS: As a result of selection, 16 publications were chosen for the analysis, including 1 meta-analysis, 2 systematic reviews and 13 RCTs. Only the results of randomised studies are presented. Endpoints referring to analgesic effects were present in all of the studies in the analysis, while endpoints referring to anti-oedema effects were present in five studies. Statistically significant results constituted 62% of the results for analgesic effects and 60% for anti-oedema effects. CONCLUSIONS: 1. The currently limited evidence from randomised studies is not sufficient to draw final conclusions on the effectiveness of cryotherapy in patients after anterior cruciate ligament reconstruction. 2. It seems that cryotherapy can serve as an adjunct analgesic treatment in the early period after arthroscopic ACL reconstruction, while there is no notable improvement in patients after this procedure in reducing oedema.

Surgery and subsequent rehabilitation for cervical spine tumours compressing neural structures.

Bone malignancies account for merely about 1.5% of all cancers, with a small percentage of these tumours developing in the cervical spine. However, the cervical spine is also the site of benign tumours and neoplasms involving not only bony tissue. Benign tumours do not metastasize but pose a threat to the spinal cord when located intrathecally. Even though such tumours do not represent malignancy, they are considered to be locally malignant. The most common cervical spine neoplasms are intradural tumours, usually extramedullary: neurofibromas, meningiomas or gliomas.Indications for surgery depend of the nature and location of the tumour and the consequences of tumour growth. Surgery is obviously necessary for intrathecal tumours compressing the spinal cord. The choice of surgical approach and manner of stabilisation depend primarily on the location of the lesion and the presence of spinal cord compression.Rehabilitation is indicated in all patients, but is particularly important, and at the same time difficult, when the growth of the tumour has resulted in neurological disturbances. The task is all the more difficult when in the presence of a massive and high spinal cord damage. Rehabilitation programmes should be designed individually for each patient and should account for the degree of paresis, stage of the underlying malignant disease, survival prognosis, disturbances in the function of other systems, apart from musculoskeletal apparatus, age of the patient, his or her commitment to treatment and other factors.The treatment of malignant neoplasms is usually associated with an unfavourable outcome. However, combination drug treatments, radiation therapy and surgery with subsequent rehabilitation will often prolong survival, ameliorate suffering and improve patients' quality of life.

[Treatment of post-traumatic instability of the cervical spine--30 years experience]. / Leczenie pourazowej niestabilnosci szyjnego odcinka kregoslupa--30 lat doswiadczen.

BACKGROUND: Assessment of the stability of the cervical spine following an injury is an important part of the diagnostic work-up. It is not always easy as the mechanism of injury does not always determine the degree of spinal stability. An actual instability is often confused with increased compensatory instability that is still within physiological limits, i. e. excessive mobility of the segment positioned above the part that has been immobilised as a result of trauma or vertebral block. Spinal injuries with instability are usually an indication for surgery. On the basis of 30 years' experience, the author presents indications for anterior approach surgery, based on the mechanism of injury and the patient's neurological status following an injury to the cervical spine. MATERIAL AND METHODS: A total of 1,225 patients have been operated on. Indications are defined for surgery using rod or plate implants and compression plates. Radiographic and neurological outcome data are presented for 1138 who had been followed up for at least 6 months. RESULTS: A good radiographic outcome was obtained in a total of 78% patients, including 84% of the recipients of rod implants and 65% of the recipients of plate implants. Neurological improvement was seen in 68% of patients with neurological symptoms, including substantial improvements in 26% of the patients. CONCLUSIONS: 1. Assessment of spinal stability is an important element of diagnostic work-up. 2. It is essential to distinguish actual instability requiring surgery from a compensatory increase in mobility of the segment lying above the immobilised segment of the spine. 3. An anterior approach procedure, apart from stabilising the spine, serves to decompress the spinal cord and offers a chance of neurological and functional improvement.

Problems of adaptation to wheelchair in early stage rehabilitation after spinal cord trauma.

Spinal cord trauma (SCT) results local and generalized complications involving cardio-respiratory system, musculo-skeletal system, digestive and urogenital tracts. Early beginning of vertical position training improves functioning and reduces risk of these complications. Wheelchair position is an important achievement in early rehabilitation of (SCT) patients. Sitting allows locomotion, enhances upper limb function and contributes to obivate complications of chronic decubity and immobilisation. OBJECTIVE: To determine main obstacles delaying adaptation to sitting during initial phase of rehabilitation after SCT. SUBJECTS: 100 patients admitted with SCT (21 women, 79 men)aged between 15 and 74 years (mean age 33,5 years) observed during first hospital stay after SCT. There were 68 patients with a complete neural deficite and 32 persons with incomplete deficite. Lesion localization: C1-C7 - 63 cases; D1-D11 - 23 cases; D12-L1 - 11 cases; below L1 - 3 cases. METHODS: Measurement of time relapsing between trauma and wheelchair adaptation. An analysis of reasons adaptation delay was performed. RESULTS AND DICUSSION: Time of adaptation ranged from 7 to 187 (mean 40,6) days. There were no significant differences in adaption time between groups of cervical, thoracic and lumbar spine injury (Kruskall-Wallis test). Patients with incomplete neural deficite adapted to wheelchair earlier (mean time 26,9 days) than ones with plegia (mean time 45,8 days) (p<0,05) The most common reason for adaptation delay was orthostatic hypotension (68 cases). Statistically significant relation between length of intensive care related to cardio-pulmonary insufficiency and adaptation delay was observed (p=0). Among other factors responsible for adaptation delay we identified sepsis (41 cases, mean adaptation time: 52,02 days, p<0,001), lack of stabile spine fusionresulting in necessity of external trunk support , concomittant extremity injury (32 cases, mean adaptation time: 54,88 days, p<0,01), deep venous thrombosis (11 cases, mean adaptation time: 49,64 days, p<0,05), bed sores (8 cases, mean adaptation time: 49,64 days, p<0,05), psychiatic disorders (7 cases, mean adaptation time: 58,29 days, p<0,05) and heterogenic ossification (7 cases, mean adaptation time: 63,67 days, p<0,05). CONCLUSIONS: 1. Orthostatic hypotension is the most common reason for delay of adaptation to sitting position in patient after SCT. 2. Other factors resulting in wheelchair adaptation delay incude: concomittant limb inuries, sepsis, psychiatric disorders, heterotopic ossification and decubitus ulcers. 3. Level of injury sex and age do not affect time of wheelchair adaptation. 4. Patients with an incomplete neural have adapt faster to wheelchair than ones with a complete neural deficite.

Cervico-cephalic syndrome in the course of degenerative disease of the cervical spine.

This article contains a synthesis of views concerning cervico-cephalic syndrome, which results from degenerative changes in the cervical spine. The pathophysiology of the syndrome is discussed, along with contemporary methods of diagnosis and therapy, with indications for conservative and surgical treatment.

The importance of verifying diagnosis in patients with spinal cord injury hospitalized in a rehabilitation department.

Background. According to Annex 7 to Resolution no. 226/2003, the National Health Fund does not cover the costs of diagnostic procedures performed in rehabilitation departments. Everyday clinical practice shows that the availability of imaging studies and specialized laboratory tests is often crucial for effective and safe patient management. The purpose of our research was to analyze the need for diagnostic procedures and verification of referral diagnosis in patients with spinal cord injury admitted to a rehabilitation department. Material and methods. We studied 175 patients (134 males and 41 females, 16 to 75 years of age, mean age 35.2 years) admitted with a diagnosis of spinal cord injury to the Rehabilitation Department of the Warsaw Medical University in the period from 1998 to 2004. Referral diagnoses were compared to the diagnoses established after examination on admission to our Department (verified diagnoses). Results. In 67 patients (38.3%) the referral diagnosis differed from the verified diagnosis. The most frequent new diagnoses included: myositis ossificans: 22 cases (12.6%), decubitus ulcers: 14 cases (8.0%); other trophic skin lesions: 9 cases (5.4%) and undiagnosed concomitant injuries: 5 cases (2.9%). 13 patients (7.5%) were disqualified from further rehabilitation and referred for surgical treatment. Conclusions. 38.3% of our patients with spinal cord injury admitted for rehabilitation had an incorrect referral diagnosis. Legislative decisions limiting the availability of diagnostic procedures at rehabilitation departments lead to decreased health care quality. Spinal cord injury patients admitted for rehabilitation require verification of the referral diagnoses, preferably by the staff of the rehabilitation department.

Radiculopathy index: a proposition of uniformed clinical examination in cervical radiculopathy.

Background. Radiculopathy is a common cause of upper limb dysfunction. Diagnosis of the disorder is based upon clinical examination. A new diagnostic tool - Radiculopathy Index - is described and experimentaly applied in patients with spondylosis related chronic cervical radiculopathy.
Material and methods. We examined 82 patients (62 women and 20 men) aged 25-77 (mean 54,2) with radicular symptoms lasting from 0,5 to 30 years (mean 5,77). Unilateral radiculopathy was diagnosed in 60 patients and bilateral syndrome was revealed in 22 patients. 104 affected limbs were analysed.
Results. 92,7% of pateints suffered from radicular pain. Sensation disturbances were noted in 69,5% of subjects. Muscular weakness was revealed in 73,1% and muscle wasting in 47,6% of cases. 39,4% of patients had reduced upper limb tendon reflexes. 86,6% of syndromes were unilevel and 13,4% were multilevel. Radicular level involvement prevalence: C6 - 42,4%; C7 - 24,6%; C5 - 17,8%; C8 - 13,5%
Conclusion. Radiculopathy Index is an appropriate and useful diagnostic tool in detecting level of involvement in cervical radiculopathy, particulary in chronic disease.

Complex management of osteoporotic vertebral fracture.

Background. Compression fractures of the thoraco-lumbar spine are the most common form of damage to the skeletal system caused by osteoporosis. These fractures are stable and do not produce neurological deficits. The intensity of the clinical symptoms depends on the degree of kyphotic distortion of the spine and the number of fractured vertebrae. Among the most serious consequences of such injuries are chronic pain, habituated poor body posture (deeper thoracic kyphosis with compensatory hyperlordosis in the lumbar spine), motor and functional limitations, reduced quality of life, and heightened risk of subsequent spinal fractures.
Material and methods. We analyzed a group of 26 patients treated for spinal fractures associated with osteoporosis, in order to evaluate the effectiveness of the treatment methods applied.
Conclusions. Our results indicate that the best outcomes are obtained when the period of immobility is reduced to a minimum and rehabilitation is commenced as early as possible.

Factors determining health awareness in persons after spinal injury with neurological complications. Pilot study.

BACKGROUND: Dedicated health education is a core intervention in comprehensive rehabilitation programmes. Health awareness of those disabled as a result of a spinal injury with neurological complications (SINC) has rarely been the subject of scientific analyses despite its importance for designing dedicated educational programs. PURPOSE: To evaluate factors determining the health awareness of persons after SINC. MATERIAL AND METHODS: 133 SINC patients (32 women) between 0.5 and 31 years after injury. An ad hoc questionnaire designed by the authors consisting of 150 detailed questions about the diagnosis, prophylaxis and management of typical health consequences of SINC. RESULTS: The mean test score (TS) was 56.6 points. TS correlated inversely with age in a statistically significant manner (correlation coefficient (CC) = -0.31). TS increased with the time elapsed since injury, with distinct increments at 1 year and 10 years after the event. Significantly higher TSs were noted in persons with university (64.6) and secondary education (65.7) compared with the rest of the group (37.9). Those unable to walk but able to use the wheelchair for independent locomotion had a higher TS (59.7) compared to wheelchair-bound persons unable to drive the wheelchair (47.5) and to persons with preserved walking ability (46.2). Significantly higher scores were achieved by inhabitants of towns above 100,000 population, those employed, members of an association for disabled persons, and respondents capable of independent self-care. There was an inverse correlation between TS and Beck's depression score (CC=-0.36). TS did not depend on gender. Interaction with other persons with SINC is perceived as the most important source of health related knowledge. CONCLUSIONS: Predictors of better health awareness in SINC persons include a young age, at least secondary education, more than 10 years since injury, participation in community rehabilitation organised by an association of persons with disability, being employed, being unable to walk, effective self-care, and absence of depression.

[Active range of cervical motion in healthy subjects and in spinal disorders. DBC equipment validity in complex cervical motion evaluation]. / Ocena ruchomosci czynnej odcinka szyjnego u osób zdrowych i w schorzeniach kregoslupa. Przydatnosc aparatury DBC w badaniu ruchu zlozonego.

UNLABELLED: Active Range of motion (AROM) is one of the crucial parameters assessed in the cervical spine evaluation. Repeated standardized AROM evaluation enables objectified monitoring of disease progress or therapy related improvement. Active spine therapy according to DBC (Documentation Based Care) requirement is a contemporary therapeutic system with proven efficacy in spinal disorders. The therapeutic concept f DBC is mechanotherapy based and introduces special devices designed for active exercises in strictly defined range, rate and load. DBC-3CR device is constructed for active motion (composed of rotation, anteflexion and lateral flexion) exercise of the cervical spine with repeated dynamic load. Technical properties allow to avail the machine for diagnostic purposes as far complex range of motion is concerned. PURPOSE: Comparison of AROM between healthy volunteers and patients with cervical disorders. Evaluation of DBC-3CR validity in complex AROM measurement Patients: A--99 healthy volunteers; B--106 patients with chronic neck pain resulting from cervical spondylosis; C--36 patients with acute neck pain related to cervical disc disease or whiplash injury. METHODS: Complex AROM detection with DBC-3CR was compared with reference measurements (goniometric and inclinometric simple AROM detection). Age and sex dependence of AROM among healthy subjects was observed. AROM was compared between B, C and reference groups. DISCUSSION: AROM was significantly decreased in patients with chronic and acute neck pain. Motion limitation pattern was symmetric in both groups. The presence of linear dependency between complex AROM acquired with DBC-3CE and rotation acquired with goniometer was observed (Pearson coefficient 0.81 at p < 0.0001). CONCLUSIONS: I. DBC-3CR device is useful in AROM evaluation. 2. AROM in healthy subjects decreases with age, but is sex--independent parameter. 3. In cervical spondylosis AROM is symmetrically reduced as far as rotation and lateral flexion are concerned. 4. Acute cervical pain results in symmetric AROM limitation.